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R  D523  G  76  A  text-book  of  surgi 


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A  TEXT-BOOK 

OF 

SURGICAL  PRINCIPLES 

AND 

SURGICAL  DISEASES 

OF  THE 

Face,  Mouth,  and  Jaws 

FOR  DENTAL  STUDENTS 


BY 

H.  HORACE  GRANT,  A.M.,  M.D, 

Professor  of  Surgery  and  of  Clinical  Surgery  in  Hospital  College  of 
Medicine ;  Professor  of  Oral  Surgery  in  the  Louis- 
ville College  of  Dentistry,  etc. 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 

J902 


i3t  "iG 


Copyright,  1902,  by  W.  B.  Saunders  &  Company. 


ELECTROTYPED   BY  PRESS  OF 

WESTCOTT  &  THOMSON.    PHILAOA,  W.    B.   SAUNDERS  &  CO.,    PHILADA. 


PREFACE 


It  is  'the  object  of  this  work  to  present  to  the  student 
of  dentistry  a  text-book  that  will  succinctly  explain  the 
principles  of  dental  surgery  applicable  to  all  operative 
procedures,  and  also  to  discuss  such  surgical  lesions  as 
are  likely  to  require  diagnosis  and  perhaps  treatment  by 
the  dentist. 

It  is  believed  that  only  such  details  as  belong  to  a 
technical  understanding  of  the  subject  are  in  place  in  a 
book  of  this  scope.  An  exhaustive  analysis  of  the 
phenomena  of  inflammation  and  repair,  as  well  as  of 
the  pathology  of  the  essential  processes  of  acute  surgical 
diseases,  is  not  desired  by  the  student  of  dentistry  during 
his  college  days,  and  the  majority  make  no  effort  to 
acquire  more  than  a  clear  understanding  of  these 
subjects. 

Again,  very  few  doctors  of  dentistry  expect  to  practice 
even  minor  surgery,  and  those  who  do  would  seek  to 
perfect  their  knowledge  in  another  theater,  and  take  as 
a  book  of  reference  some  of  the  more  pretentious  works 
on  surgery.  Hence  it  is  unprofitable  for  the  dental 
student,  during  his  college  course,  to  purchase  a  work: 
that  is  so  prolific  in  detail  as  to  be  bulky,  or  that  is  in 
large  part  devoted  to  subjects  in  which  he  has  nO' 
practical   interest. 

It  is  believed  the  arrangement  and  subject-matter  of 
this  book  will  be  found  to  cover  the  needs  of  the  dental 

5 


O  PREFACE. 

student  without  encumbering  him  with  any  details 
foreign  to  the  course  usually  taught  in  the  colleges  at 
this  day.  The  book  makes  no  claim  to  original  thought. 
The  author  has,  in  his  own  language  and  in  the  simplest 
way,  given  the  accepted  views  of  surgical  principles  and 
such  diseases  as  are  herein  discussed.  No  authorities 
are  cited,  as  the  aim  of  the  book  is  to  get  the  most 
facts  in  the  least  space  compatible  with  intelligent 
instruction. 

The  book  is  submitted  with  the  hope  that  it  will  be 
found  useful  to  that  class  for  which  it  is  designed. 

H.  H.  GRANT. 

September  i,  igo2. 


CONTENTS. 


CHAPTER  I. 

PAGB 

Bacteriology  and  Surgical  Principles ii 

CHAPTER  II. 
Inflammation 19 

CHAPTER  III. 
Inflammation  (Continued).     Suppuration.    Abscess    ....    25 

CHAPTER  IV. 
Ulcerations — Ulcers.     Sinus  and  Fistula.     The  Processes   of 
Repair 31 

CHAPTER   V. 
Gangrene.     Thrombosis  and  Embolism 38 

CPIAPTER  VI. 
Auto-infection.     Surgical  Fever.     Sapreniia  and  Septicemia  .    43 

CHAPTER  VII. 
Pyemia.     Erysipelas.     Actinorhj'cosis 50 

CHAPTER  VIII. 
Surgical  Diagnosis.     Preparations  for  Operation 57 

CHAPTER  IX. 
Anesthesia.     Local  and  General 63 

CHAPTER   X. 
Wounds,  Including  Shock 71 

7 


CONTENTS. 

CHAPTER  XI. 


PAGE 


Emergencies— Hydrophobia.  Epilepsy.  Apoplexy.  Sun- 
stroke. Foreign  Bodies  in  the  Eye,  Nose,  Ear,  and  Air- 
passages.    Burns 7^ 

CHAPTER  XII. 
Hemorrhage 85 

CHAPTER  XIII. 
Tumors 9^ 

CHAPTER  XIV. 
Tumors  (Continued).     Carcinoma 102 

CHAPTER  XV. 
Tumors  (Concluded).     Sarcoma.     Cysts 108 

CHAPTER  XVI. 
Syphilis ' • i^5 

CHAPTER  XVII. 
Tuberculosis  of  the  Bones,  Skin,  and  Mucous  Membranes  .    .  125 

CHAPTER  XVIII. 
Diseases  of  the  Bones  and  Lymphatics 131 

CHAPTER  XIX. 
Diseases  and  Ulcerations  of  the  Gums  and  Mouth 139 

CHAPTER  XX. 
Tumors  of  the  Gums  and  Alveolar  Border,  Including  Dis- 
ease of  the  Bones  of  the  Jaw i43 

CHAPTER   XXI. 
Surgical  Lesions  of  the  Mouth  and  Face 156 

CHAPTER  XXII. 
Surgical  Lesions  of  the  Face  (Continued).    Sebaceous  Tu- 
mors.    Keloid.     Surgery  of  the  Nose 164 


CONTENTS.  9 

CHAPTER  XXIII. 

FACE 

Cleft-palate.     Harelip 171 

CHAPTER  XXIV. 
Lesions  of  the  Lips  and  Tongue 179 

CHAPTER  XXV. 
Diseases  of 'the  Salivary  Glands.     Salivary  Calculi  and  Sali- 
vary Fistula.     Ranula 187 

CHAPTER  XXVI. 
Diseases  of  the  Maxillary  and  other  Sinuses.     Empyema  of 
the  Antrum.     Cysts  and  Polypi.     Acromegaly 193 

CHAPTER  XXVII. 
Neuralgia  .    .   . 199 

CHAPTER  XXVIII. 

Dislocations,  with  Special  Reference  to  the  Inferior  Maxilla. 

Ankylosis  of  the  Lower  Jaw 204 

CHAPTER  XXIX. 
Fractures,   with   Special   Descriptions   of  the   Bones  of  the 
Face.     Fractures   of   the   Lower  Jaw.     Fracture  of  the 
Nasal  Bones 213 

Index 225 


CHAPTER  I. 
BACTERIOLOGY. 

From  our  present  knowledge  we  deduce  that  the 
basis  of  surgical  pathology  is,  without  question,  germ 
infection,  and  consequently  the  study  of  this  subject 
becomes  that  of  bacteriology.  With  the  advance  of  this 
view  of  disease  the  older  theories  were  left  behind  and 
the  possibilities  of  present  surgery  were  contemplated 
and  achieved. 

Bacteria  is  the  generic  term  for  microbic  organisms. 
These  microbes  are  of  the  lowest  order  of  the  vegetable 
kingdom,  and,  unlike  ordinary  parasites  of  insect  life, 
are  without  volition,  and  often  without  motion,  though 
some  forms  have  undirected  movements  called  "ame- 
boid," like  the  movements  of  wandering  blood-corpus- 
cles and  free  cells  in  the  tissues. 

A  bacterium  consists  of  a  cell  composed  of  protoplasm 
or  glue-like  mass,  surrounded  by  a  thin  membrane. 
Some  have  a  distinct  coloring-matter,  while  others  are 
pale. 

Germs  are  found  everywhere;  every  touch  of  clothing 
or  finger  contact  carries  with  it  to  wounded  surfaces 
countless  numbers  of  bacteria.  Usually  three  forms 
are  recognized:  the  micrococci  ox globiday- — far  the  most 
numerous;  the  bacilli,  or  rod -shaped ;  the  spirilla,  or 
spiral-shaped. 

All  acute  inflammatory  processes,  whether  in  the 
domain  of  surgery  or  medicine,  are  caused  by  bacterial 
infection. 

Not  all  bacteria  tend  to  pathologic  manifestations, 
many  germs  being  harmless.  Those  tending  to  produce 
disease  are  termed  pathogenic.     Some  have  special  fuuc- 

H 


12  BACTERIOLOGY. 

tions,  as  the  pus-producing,  QdW^^  pyogenic.  Some  pro- 
duce special  disease,  as  the  micrococcus  of  pneumonia, 
term&di  p7teiimocGCC2is  ;  or  that  of  gonorrhea,  termed^cw^- 
cocciis.  Some  produce  decomposition,  and  are  termed 
saprogenic  germs. 

When  micrococci  in  process  of  development  are  arranged 
in  pairs,  they  are  termed  diplococci ;  when  in  clusters, 
like  a  bunch  of  grapes,  staphylococci ;  and  when  in  rows, 
like  a  chain,  streptococci. 

Bacteria  require  favorable  conditions  for  development, 
and  though  they  grow  best  in  the  human  body,  under 
certain  favorable  conditions  and  special  precautions  they 
may  be  cultivated  in  an  artificial  medium  of  gelatin. 

The  cocci  multiply  by  direct  division  or  fission,  and 
with  such  rapidity  that,  in  the  space  of  twenty-four 
hours  and  under  favorable  conditions,  one  coccus  may 
multiply  to  15,000,000  or  more. 

The  bacilli  multiply  more  slowly  by  a  spore  or  bud- 
ding process;  also  by  transverse  division.  As  will  be 
seen  later,  the  moisture  and  the  temperature  of  the  body 
are  most  favorable  for  this  growth. 

In  the  presence  of  colonies  of  saprogenic  bacteria,  in 
decomposing  tissues,  there  is  developed  a  poisonous  alka- 
loid called  pto7nain. 

Ptomains  are  not  a  secretion  from  bacteria,  nor  has  it 
been  proved  that  they  emanate  from  them.  They  develop 
in  the  presence  of  bacteria,  and  thus  are  formed  some  of 
the  so-called  toxins  of  septic  infection. 

Such  poisonous  germs  develop  in  decomposing  and  im- 
properly cooked  food,  and  cause  severe,  and  sometimes 
fatal,  symptoms.  For  example,  the  so-called  tyrotoxicon 
in  ice-cream  and  spoiled  milk,  and  the  ptomains  in 
chicken  salad,  etc. 

These  toxins  are  the  causative  agents  of  sapremia,  the 
blood-poisoning  due  to  retained  after-birth  in  labor  and 
abortion,  and  to  sloughs  and  gangrene.  Forms  of  the 
toxins  of  pathogenic  bacteria,  rendered  less  virulent  by 
attenuation,    constitute    the   antitoxin    serums   used   to 


DESTRUCTION    OF    BACTERIA.  1 3 

prevent  and  cure  diseases,    as   diphtheria   and    tetanus. 
Vaccination  likewise  is  in  a  degree  an  example. 

Most  forms  of  bacteria  flourish  best  at  the  temperature 
of  the  body,  with  the  natural  moisture  of  the  tissues. 
Hence  after  an  injury  in  which  the  vessels  are  broken,  a 
favorable  lodging  and  nourishing  field  for  multiplication 
is  furnished.  Such  conditions  as  are  opposed  to  warmth 
and  moisture  tend  to  retard  or  prevent  multiplication. 
The  freezing-point  destroys  many  forms  of  germs  but  is 
less  destructive  to  spores.  Heat  is  much  more  reliable 
as  a  destructive  agent  to  these  microbes,  and  moist  heat 


Fig.  I. — Staphylococcus  pyogenes  aureus  ;  pure  culture  on  blood-serum  after 
twenty-four  hours  at  22°  C.  (Ernst). 

or  boiling  water  will  more  promptly  destro}^  them  than 
dry  heat.  The  latter  at  a  high  grade,  sustained  for  some 
thirty  minutes  to  an  hour  or  more,  is  employed  in  the 
sterilization  of  surgical  dressings. 

It  is  manifest,  however,  that  such  measures  are  inap- 
plicable to  living  tissues,  and  here  certain  chemical 
germicides  are  employed.  The  most  common,  as  well 
as  the  cheapest,  and  perhaps  fully  equal  to  any  other  in 
value,  is  corrosive  sublimate  or  bichlorid  of  mercury. 
On  fresh  wounds  it  cannot  well  be  used  in  stronger  solu- 
tion than  I  :  500,  and  then  is  safe  only  on  very  small  siir- 
faces.     It  is  usualh'  employed  in  solutions  of  1:1000  or 


14  BACTERIOLOGY. 

i:  1500,  or  even  in  weaker  strength.  As  it  rusts  instru- 
ments, it  cannot  be  employed  to  sterilize  them.  After 
boiling  for  a  short  time,  sterilized  knives,  scissors,  and 
needles  are  best  placed  in  i :  30  solution  of  carbolic  acid. 
Other  instruments  should  be  well  boiled  in  plain  water, 
and  then  wrapped  in  a  sterilized  towel  until  required  by 
the  operator. 

Formalin,  in  the  strength  of  i :  10,000,  is  valued  highly 
as  an  irrigating  fluid  in  suppurating  surfaces. 

Iodoform  is  seldom  used  as  a  local  applicant,  owing  to 
its  feeble  effect   and  its  offensive  odor.     A  variety  of 


S  ■•-       •  '^  J   ■ 


r^--. 


«•-%. 


V    •■" 


Fig.  2. — Streptococcus  pyogenes  ;  bouillon  culture,  twenty- four  hours  (Ernst). 

germicides  are  employed,  all  having  the  same  general 
effect,  but  none  surpassing,  for  general  service,  those  here 
recommended. 

In  order  to  produce  a  pathologic  manifestation  bacteria 
must  exist  in  large  colonies,  otherwise  the  resistance  of 
nature  will  prevent  any  effect.  It  is  estimated  that  it 
requires  one-third  of  a  billion  of  the  cocci  of  suppuration 
to  produce  a  small  abscess.  Thus  it  appears  that  such 
results  of  infection  necessitate  at  least  from  thirty  to  fifty 
hours  to  permit  of  the  multiplication  of  a  focus  to  such 
a  multitude. 

By  antisepsis  is  meant  the  destruction  of  such  colonies, 


FORMS    AND    VARIETIES    OF    BACTERIA.  I5 

either  before  they  have  reached  the  damage-producing 
stage  or  after  their  effects  are  evident. 

By  asepsis  is  meant  the  prevention  of  the  admission 
of  pathogenic  germs  to  wounded  surfaces. 

As  antiseptics  or  germ  destroyers  on  living  tissues, 
such  solutions  as  have  been  mentioned,  while  not  destroy- 
ing all  the  germs  in  the  tissues,  render  the  soil  less  favor- 
able for  their  nutrition,  and  thus  prevent  and  retard 
colonization. 

Although  pathologic  bacteria  are  not  usually  found  in 
healthy  tissues,    still  they  undoubtedly  circulate  harm- 


^ 


,-  • 


\ 


v« 


,^r        .^ 


^ 


■;  • 


Fig.  3. — Tetanus  bacillus  ;  old  culture  on  bouillon,  showing  battledore  forms 
and  free  spores  (Ernst). 

lessly  in  the  vessels  in  many  instances.  In  the  course  of 
their  progress  through  the  vessels  they  come  upon  a  spot 
favorable  for  colonization,  when  they  produce  a  patho- 
logic demonstration  in  the  absence  of  any  open  wound. 
By  all  odds,  however,  the  usual  mode  of  admission  is 
through  an  acute  wound  or  abrasion  of  the  skin. 

Granulating  wounds  and  old  ulcers  do  not  readily 
admit  germs. 

The  forms  of  bacteria  most  commonly  encountered  by 
the  surgeon  are  those  of  suppuration,  termed  pyogenic 
or  pus-making  microbes.'     These  germs  are  of  the  form 


1 6  BACTERIOLOGY. 

of  cocci,  arranged  either  in  groups  or  in  bunches,  are  of 
a  yellow  color,  and  are  called  staphylo-  {clustering)  coccus 
pyogenes  {pus-niaki7ig)  aiu^ens  {yellow)^  or,  when  in 
rows,   strepto-  {chain-like)  coccus  pyogenes. 

The  staphylococcus  pyogeiies  aureus  is  a  microscopic, 
globular-shaped  germ,  which  multiplies  by  fission,  is 
very  difficult  to  destroy,  and  grows  rapidly.  It  usually 
requires  from  sixty  to  seventy-two  hours  after  inoculation 
to  produce  pus.  It  is  found  in  abundance  everywhere — 
in  the  atmosphere  and  upon  all  exposed  surfaces  of  the 
body  and  of  other  objects.  It  often  exists  in  wounds  the 
seat  of  other  germs. 

Streptococcus  pyogeties  is  a  less  common  germ.  It  is 
arranged  in  chains  or  rows,  and  is  usually  found  in  more 
virulent  or  phlegmonous  suppurations  and  in  rapidly 
spreading  inflammations  attended  by  much  pus-forma- 
tion. 

These  cocci  are  found  in  all  acute  abscesses,  either 
alone  or  mixed.  In  order  to  produce  symptoms,  about 
250,000,000  are  required,  and  a  state  of  the  tissues  favor- 
able to  their  nutrition  is  necessary. 

Practically  speaking,  suppuration  never  takes  place  in 
the  absence  of  these  germs,  though  experiments  have 
proved  that  the  injection  of  certain  chemical  irritants 
may  at  times  produce  a  pus-like  discharge  without  the 
presence  of  the  germs. 

Other  forms  of  bacteria  of  special  character  produce 
certain  manifestations,  and  often  bear  the  name  of  the 
disease  they  give  rise  to. 

The  bacillus  of  tetanus  produces  lockjaw.  From  its 
shape  it  is  called  drumstick  bacillus.  It  grows  best  in 
moist  manure,  and  can  be  found  about  horse-stables. 

The  bacillus  of  tuberculosis  is  small,  thin,  and  rod- 
shaped,  non-motile,  and  usually  not  abundant  in  the 
tissues.  These  bacilli  are  not  easily  destroyed,  and 
possess  the  power  of  multiplying  for  years,  even  in  a 
quiescent  state.  They  do  not  grow  well  in  an  artificial 
medium,  but  when  once  located  in  the  tissues,  though 


SUMMARY. 


17 


making  slow  progress,  are  almost  incapable  of  destruc- 
tion by  any  means  except  excision  of  the  infected  parts. 

The  bacillus  of  anthrax  is  found  in  virulent  carbun- 
cles and  malignant  pustule,  and  is  very  difficult  to  de- 
stroy. 

The  gonococcus,  as  has  been  demonstrated  by  Neisser, 
produces  gonorrhea. 

The  pneumococcus  is  found  in  the  sputum  of  pneu- 
monia patients.     Many  other  special  germs  exist. 

It  is  to  be  borne  in   mind    that  these  germs  are  not 


/    ^     ^> 


1./    '   (-.: 


^@L 


a 


Fig.  4. — Bacillus  tuberculosis  in  human  gland  (Ernst). 

usually  visible  to  the  eye  even  under  the  microscope, 
unless  stained  artificially  in  a  special  manner,  some 
reactino;  to  one  stain  and  some  to  another. 


SUMMARY. 

We  find,  in  looking  over  the  facts  just  stated,  that  the- 
primary  cause  of  all  surgical  diseases  is  the  presence  and 
colonization  of  germs,  for  which  the  general  term  is 
bacteria  ;  that  such  germs  are  of  practically  two  forms, 
though  of  many  varieties  ;  that  they  gain  entrance  to 
the  body  chiefly  through  wounds  and  abrasions  ;  that 
they  multiply  by  direct  division  and  by  a  process  of 
2 


15  BACTERIOLOGY. 

budding,  and  with  such  rapidity  that  one  will  become 
15,000,000  in  twenty-four  hours  ;  that  they  are  every- 
where ;  that  not  all  forms  are  capable  of  producing  dis- 
ease ;  that  pathogenic  bacteria  cause  special  results  or 
diseases,  and  that  some  varieties  produce  ptomains  and 
other  toxins,  or  poisons  of  great  virulence. 

Further,  that  bacteria  grow  best  amid  moist,  warm 
surroundings,  as  near  the  temperature  of  the  human  body 
as  possible.  That  they  are  susceptible  of  destruction 
by  heat,  cold,  and  chemicals  ;  and  that  some  special 
forms  produce  constantly  the  same  special  diseases  or 
effects. 


CHAPTER    II. 
INFLAMMATION. 

The  basis  of  nearly  all  pathologic  change  in  one  or 
another  of  its  forms  is  infiajnmatioii.  A  knowledge  of 
the  phenomena  accompanying  inflammation  is  therefore 
essential  to  an  understanding  of  disease. 

Inflammation  is  defined  as  a  persistent  disturbance  of 
the  function  of  nutrition,  characterized  by  heat,  redness, 
pain,  swelling,  and  disturbance  of  the  function  of  the 
part  affected. 

It  is  the  belief  of  the  author  that,  up  to  the  stage  of 
infection,  the  steps  in  the  process  of  normal  repair  are 
identical  with  those  of  inflammation,  differing  only  in 
degree.  In  his  teaching  of  this  subject  he  has  for  years 
adopted  a  division  into  physiologic  or  reparative  inflam- 
mation, and  pathologic  or  destructive  inflammation  ;  the 
first  occurring  without  any  infection  ;  the  latter  due  to 
bacteria. 

Any  irritation,  however  temporary,  sends  an  undue 
amount  of  blood  to  the  part.  If  the  irritation  is  mo- 
mentary, this  is  termed  a  blush  or  suffusion ;  if  it  is 
more  prolonged,  but  still  temporary  and  without  struc- 
tural alteration,  it  is  termed  hyperemia ;  if  still  more 
persistent,  it  is  congestion^  and  later  stagnation. 

We  understand  by  the  term  hyperemia  a  persistent 
determination  of  blood  to  the  part,  a  condition  commonly 
called  congestion.  Arterial  congestion  is  called  active., 
and  venous  congestion /^^^/z'^  hyperemia.  Acute  hyper- 
emia is  due  to  some  mechanical  or  chemical  irritation. 
Chronic  hyperemia  is  the  result  of  a  moderate  but  per- 
sistent irritation. 

When    either    form    of   hyperemia    persists    there    is 

19 


20 


INFLAMMATION. 


offered  a  favorable  field  for  germ  infection,  and  the  proc- 
esses of  inflammation  are  set  up.  The  result  is  the 
formation  of  an  exudate,  the  escape  of  the  products  of 
inflammation.  As  this  exudate  becomes  organized  and  a 
new  tissue  is  formed  there  results  what  is  called  a  hyper- 
plasia^ which  is  simply  an  increase  of  tissue-cells.  If 
this  hyperplasia  include  all  the  cells  of  the  part,  it  is 
called  hypertrophy.  True  hypertrophy  is  not  inflamma- 
tory, but  is  a  multiplication  and  development  of  all 
the  cells  of  the  part,  so  as  to  increase  in  every  direction 
the  contour  and  extent  of  the  limb  or  other  tissue  in- 


FlG    5  — Circulation  in  hyperemia  (Warren). 


volved.  A  chronic  hyperplasia  may  alter  the  shape  and 
appearance  of  the  part  disastrously,  but  this  is  the  result 
rather  of  infiltration  than  of  growth. 

Owing  to  a  diminished  blood-supply,  due  to  the  presence 
of  the  exudation  from  the  vessels  or  to  impaired — so-called 
trophic — nerve  changes,  the  size  of  a  limb  may  greatly 
diminish  oi  the  limb  may  waste  away.  This  process 
is  termed  atrophy.  Even  paralysis  may  succeed  this 
change. 

If,  after  ordinary  suffusion  and  even  hyperemia,  the 
irritation  stops,  no  leak  occurs  in  the  vessels,  and  the 


DIAPEDESIS. 


21 


normal  condition  is  resumed  without  any  other  phenom- 
ena. When,  however,  the  irritation  still  persists,  the 
vessels  dilate,  the  red  corpuscles  increasing  in  number, 
and,  being  heavier,  seeking  the  center  of  the  blood- 
current. 

The  white  corpuscles  still  more  proportionately  increase 
in  number,  and  are  thrown  toward  the  "shore,"  or  walls 
of  the  vessels.  A  little  later  the  current  slows,  by  reason 
of  its  crowded  condition,  and  the  white  corpuscles  are 


Fig.  6. — Passive  hyperemia  (Warren). 


forced  through  the  walls  of  the  veins  by  an  outward 
movement.     This  transmission  is  termed  diapedesis. 

Along  with  the  white  corpuscles  which  wander  into 
the  cellular  tissue  the  serum  of  the  blood  also  escapes. 
As  a  result  of  these  processes  a  substance  termed  yfZrzVz  is 
formed,  which  causes  injured  tissues  of  both  concealed 
and  open  wounds  to  adhere,  and  thus  repair  begins. 

All  this  creates  an  inviting  spot  for  any  germ  wander- 
ing in  the  blood,  or  gaining  admission  through  an  open 
wound,  to  establish  a  colony.  Up  to  this  point  the  steps 
in  both  forms  of  inflammation  are  identical,  except  in 


22  INFLAMMATION. 

degree.  If  the  powers  of  nature  are  sufficient,  infection 
is  resisted  and  repair  begins.  If  infection  occur,  the 
destructive  processes  are  at  once  inaugurated. 

The  inquiry  is  natural  that  as  injuries  and  irritations 
happen  daily  to  almost  every  member  of  the  human 
family,  and  as  the  germs  are  everywhere,  why  is  it  septic 
wounds  are  not  universal  ?  Truly  such  would  be  the  case 
were  it  not  for  the  resistant  powers  of  nature.  All  bac- 
teria are  to  be  regarded  as  enemies  resisted  by  the  home- 
guards.  This  resisting  power  of  nature  is  largely  found 
in  the  white  blood-corpuscles,  or  leukocytes.  These  sol- 
dier leukocytes  are  termed  phagocytes^  and  they  surround 
the  invading  bacteria,  resisting  and  encapsulating  them. 
This  is  termed  phagocytosis.  If  successful,  the  infection 
is  prevented,  or  perhaps  only  limited  ;  if  the  bacteria  are 
not  overpowered,  however,  a  pathologic  inflammation  is 
the  result.  We  have  seen  how  any  persistent  irritation 
increases  the  number  of  leukocytes  enormously  ;  hence 
these  reinforcements  are  present  to  resist  the  invaders. 

The  influence  which  attracts  the  leukocytes  to  the  point 
favorable  for  colonization  of  bacteria  is  called  chemotaxis. 
By  this  same  influence  also  the  bacteria  attract  to  them- 
selves material  for  nourishment  and  growth. 

We  have  seen  that  the  local  symptoms  of  inflammation 
are  constantly  heat.^  redness.^  pain^  swelling.^  and  mipaired 
functioning  of  the  part.  These  are  easily  accounted  for. 
The  increased  blood-supply  causes  the  heat  and  redness. 
The  injury  to  the  nerves  and  the  pressure  upon  them 
by  the  escaped  leukocytes — blood-serum  and  exudates — 
cause  the  pain,  and  in  the  same  way  the  swelling  is 
accounted  for. 

The  impairment  of  function  is  due  partly  to  the  physi- 
ologic changes  and  partly  to  the  pain  caused  by  effort. 

All  inflammation  must  have  an  original  irritation,  and 
for  all  practical  purposes  this  is  a  colony  of  bacteria, 
which,  whenever  located  successfully,  resists  the  phago- 
cytes and  creates  a  persistent  and  progressive  disturb- 
ance of  the  nutrition  of  the  part. 


CONSTITUTIONAL    SYMPTOMS.  2$ 

Any  spot  inviting  the  location  of  such  a  colony  is  a 
predisposing  cause.  Such  spot  is  termed  point  of  les- 
sened resistance — a  locus  minoris  resistentia. 

Inflammations  derive  their  qualifying  names  in  some 
instances  from  their  character  and  tendency  ;  those  of  a 
high  grade  are  called  sthenic^  those  of  feeble  vigor,  asthe- 
nic. Those  involving  serous  membranes  are  so  named, 
whereas  adhesive  or  Jibroits  inflammations  indicate  their 
character  in  tendency  to  glue  the  parts  together.  Sup- 
purative are  those  producing  pus  ;  phlegmonous  are 
spreading  inflammations,  involving  cellular  tissue,  often 
causing  a  burrowing  abscess.  Hemorrhagic  and  gan- 
grenous inflammations  define  themselves. 

The  constitutional  symptoms  of  inflammation  are  con- 
stant in  character,  but  vary  in  degree  with  the  acuteness 
and  severity  of  the  infection. 

The  fever  of  inflammation,  which  varies  from  the 
slight  elevation  of  the  temperature  in  the  physiologic 
process  to  the  limit  seen  in  virulent  septic  infection, 
usually  ranges  in  the  pathologic  form  between  ioi°  to  103° 
F.,  with  malaise,  headache,  coated  tongue,  con.stipation, 
cold  extremities  and  a  feeling  of  chilliness,  followed  by  hot 
flashes.  The  chilly  feelings  or  rigors.,  as  they  are  called, 
are  distinct,  and  often  ver}'  pronounced  chills  occur  in 
the  more  severe  infections.  If  the  inflammation  involve 
a  functionating  organ,  as  the  lungs,  pleura,  bladder,  etc., 
pain  upon  function  as  well  as  upon  manipulation  or 
pressure  will  follow. 

Subacute  inflammation  is  usually  understood  to  be  a 
mild,  slowly  progressing  form,  due  to  some  germ  not 
possessing  marked  destructive  powers,  as  those  of  rheu- 
matism, syphilis,  etc. 

Chronic  inflammations  exhibit  much  milder  symptoms, 
both  local  and  constitutional,  than  those  characterizing 
the  acute,  but  extensive  destructive  changes  may  go  on 
in  either  soft  parts  or  bone  and  lead  to  suppuration  and 
ulceration. 

Inflammation    terminates  in   resolution^ — a   return   to 


24  INFLAMMATION. 

normal  condition, — death  of  the  part  by  suppuration 
and  gangrene,  or  death  of  patiejit  by  exhaustion  from 
sepsis. 

Resolution  is  understood  to  be  a  victory  for  the  phago- 
cytes, an  absorption  of  the  effusion  and  a  removal  of  the 
irritation — a  prevention  of  destruction. 

Death  of  the  part  by  suppuration  and  gangrene  will 
be  described  under  the  respective  headings. 

The  course  and  termination  of  inflammation  may  then 
be  looked  upon  as  resolution  or  the  subsidence  of  the 
process,  or  destruction  with  death  of  the  part. 

By  resolution  is  meant  that  the  efforts  of  nature,  partly 
by  phagocytosis  and  perhaps  partly  by  other  favoring 
influences,  have  resisted  infection.  After  a  variable  time 
the  exudates  are  absorbed  and  the  parts  return  to  quite 
or  almost  the  original  condition.  This  is  the  most  com- 
mon termination.  Destruction,  however,  may  occur  in 
several  ways,  as  by  suppuration,  ulceration,  gangrene,  etc. 
Usually  suppuration  results  when  the  inflammation  con- 
tinues. Pus  consists  of  the  liquor  pui^is^  or  serum,  with 
broken-down  leukocytes,  dead  and  dying,  and  the  waste 
of  perished  connective-tissue  cells.  By  suppurative  in- 
flammation is  meant  that  inflammation  which  produces 
pus. 

An  abscess  is  a  collection  of  pus  inclosed  in  or  circum- 
scribed by  the  tissues.  If  this  collection  of  pus  is  infil- 
trated through  the  tissues  without  any  distinct  limiting 
wall,  it  is  termed  a  purulent  infiltration,  or,  more  com- 
monly, as  applying  to  general  structures,  a  phlegmonous 
inflammation. 

The  circumscribed  abscess,  acute  in  character,  is 
usually  due  to  the  staphylococcus  (grape-shaped  coccus). 
The  phlegmonous  and  infiltrated  form  usually  contains 
the  streptococcus  and  is  more  destructive  in  tendency. 


CHAPTER    III. 
INFLAMMATION  (Continued). 

TREATMENT. 

The  treatment  of  inflammation  is  both  local  and  con- 
stitutional. 

I/Ocal  Treatment.  —  The  local  treatment  consists 
chiefly  in  rest  of  the  part  and,  in  the  earliest  stages,  the 
application  of  evaporating  lotions.  Occasionally  it  may 
be  necessary  to  extract  blood  by  means  of  punctures  or 
the  application  of  leeches,  or  what  are  known  as  "wet 
cups."  In  the  majority  of  cases,  however,  soothing  ap- 
plications are  employed.  These  applications  should  be 
either  cold  or  hot,  as  comforts  the  patient  most.  Over 
small  inflamed  surfaces  the  application  of  cold  is  often 
followed  b}^  a  subsidence  of  determination  of  blood  to  the 
part  and  the  promotion  of  resolution.  Larger  surfaces 
are  usually  better  treated  by  the  application  of  heat,  in 
the  form  of  poultices,  hot  cloths  wrung  out  of  antiseptic 
solutions,  hot-water  bags,  and  other  measures  of  a  similar 
nature.  Such  applications  are  not  usually  made  directly 
over  fresh  wounds,  but  are  more  commonly  made  to  ab- 
scesses, either  to  those  forming  or  those  already  formed, 
and  to  angry  wounds  and  sloughs. 

Elevation  of  the  part,  together  with  its  fixation  in 
splints,  if  the  site  of  inflammation  be  upon  an  extremity, 
is  a  valuable  means  of  treatment. 

Inflammations  that  are  not  very  severe,  especialh- 
those  of  the  subacute  or  chronic  type,  are  often  benefited 
by  evaporating  lotions,  of  which  the  best,  perhaps,  is  the 
well-known  "  lead-and-opium  "  solution.  The  strength 
of  this  lotion  should  be  one  part  of  the  tincture  of  opium 
to  four  parts  of  dilute  lead-water. 

25 


26  INFLAMMATION. 

Various  other  lotions  are  employed  for  the  same  pur- 
pose and  with  similar  result. 

Phlegmonous  inflammations,  and  those  which  threaten 
deep-seated  suppuration,  are  to  be  treated  by  free  incisions 
and  irrigation  with  antiseptic  solutions.  Perhaps  the 
best  antiseptic  solution  is  bichlorid  of  mercury  in  the 
strength  of  i  to  looo  parts  of  water.  Accumulations  of 
pus  should  be  opened  promptly,  evacuated  thoroughly, 
irrigated  antiseptically,  and  drained.  In  the  more  chronic 
forms  of  inflammation  stimulating  applications,  as  the 
tincture  of  iodin,  or  even  fly  blisters,  and  massage,  com- 
pression, and  support  by  bandages  are  measures  often 
indicated. 

Constitutional  Treatment. — This  is  controlled  largely 
by  the  character  of  the  case.  In  the  simpler  and  less 
severe  forms  rest  and  the  usual  rational  steps  are  all  that 
is  required.  In  the  acute  inflammations  of  high  grade 
the  temperature  should  be  reduced  by  sponging  and  by 
the  administration  of  some  of  the  well-known  anti- 
pyretics. 

In  those  cases  in  which  the  fever  continues  and  a  con- 
dition of  blood-poisoning  is  superadded,  the  patient 
sinking  into  what  is  known  as  the  "typhoid  state," 
stimulation  with  whisky  and  the  administration  of 
strychnin  and  quinin  are  early  indicated.  The  adminis- 
tration of  opium  to  secure  rest  and  relieve  pain  fills  even 
the  more  imperative  want  of  repose  to  the  whole  system, 
and  should  be  given  when  indicated. 

The  administration  of  purgatives  should  be  relied 
upon  to  keep  the  bowels  well  open,  and  free  purgation 
is  valuable  in  inflammation  in  most  situations  of  the 
body. 

The  bromids  often  answer  a  satisfactory  purpose  in 
quieting  the  headache  and  restlessness  in  elevated  tem- 
peratures, and,  when  pain  is  not  the  prominent  symptom, 
should  be  used  in  preference  to  opium.  In  the  author's 
experience  antipyrin  and  antikamnia  answer  a  good  pur- 
pose in  the  restlessness  and  fever  of  acute  inflammation. 


SUPPURATION.  2^ 

In  the  earlier  stages  of  all  cases  of  inflammation  the 
diet  should  be  what  is  known  as  the  soft  diet,  consisting 
of  milk,  eggs,  broth,  with  toasted  bread,  and  only  the 
very  lighter  articles  of  food.  The  artificial  foods,  many 
of  which  are  already  peptonized  or  digested  before  ad- 
ministration, are  often  found  to  be  of  great  service.  A 
little  later,  when  the  acute  stage  has  passed,  or  often 
throughout  the  chronic  forms,  stimulation  of  a  less  pro- 
nounced character,  with  tonic  doses  of  iron,  quinin,  or 
strychnin,  and  the  administration  of  a  more  liberal  diet, 
constitute  the  indications. 


SUPPURATION. 

By  this  term  is  meant  the  formation  of  the  liquid 
known  ^.s  pus.  So  far  as  practical  surgery  is  concerned, 
we  know  this  to  be  accomplished  by  the  colonization  of 
the  germs  of  suppuration,  almost  exclusively  the  staphy- 
lococcus and  the  streptococcus.  Predisposing  causes, 
some  of  which  we  have  studied,  tend  to  effect  this  col- 
onization. 

Septic  cocci,  introduced  from  without  or  circulating 
in  the  blood,  even  when  they  find  a  place  favorable  to 
colonization,  are  tens  of  thousand  times  destroyed  by 
phagocytosis  before  a  colony  can  be  formed.  When  the 
predisposition  permits  of  a  colony  up  to  200,000,000  or 
300,000,000,  pus  is  formed. 

Pus  is  ordinarily  a  light,  yellow-looking  fluid,  of  a 
varying  consistency,  composed  of  a  sediment,  wdiich 
deposits  on  standing,  and  a  pale  serum.  It  is  familiar 
to  everybody.  The  serum  has  a  peptonizing  or  soften- 
ing effect  on  tissues,  and  some  forms  rapidly  destroy 
cellular  and  less  dense  tissues.  The  sediment  consists 
chiefly  of  broken-down  tissues,  altered  leukocytes,  here 
termed  pus-corpuscles,   and  micro-organisms. 

Pus  varies  in  color  according  to  its  location,  its  viru- 
lence, and  germs  present.  The  odor  is  sometimes  quite 
noticeable  and  even  offensive.     When  blood  is  fully  inter- 


28  INFLAMMATION. 

mingled  with  the  pus,  it  is  called  ichorous^  and  if  merely 
combined  with  it,  hejuori-hagic. 

Pus  is  to  be  considered  as  the  debris  of  the  conflict 
between  the  leukocytes  and  the  bacteria,  with  a  victory 
for  the  latter.  When  pus  is  produced  in  an  open  wound 
and  free  drainage  is  permitted,  the  symptoms  of  inflam- 
mation are  usually  not  increased,  but  when  the  discharge 
is  interfered  with  and  the  collection  is  under  the  skin 
and  tissues,  without  drainage,  constitutional  and  local 
symptoms,   sometimes  of  severe  magnitude,   supervene. 

Infection  of  a  wound,  even  to  a  moderate  degree,  is 
attended  with  more  or  less  increase  of  pain,  redness,  and 
throbbing,  from  which  free  escape  of  the  discharge 
usually  gives  marked  relief  But  pent-up  pus  under  any 
circumstances  presents  symptoms  better  described  under 
the  head  of  abscess. 

An  abscess  is  a  collection  of  pus,  usually  circumscribed 
by  a  limiting  wall.  This  collection  results  from  the  col- 
onization of  the  cocci  of  suppuration,  the  colony  strug- 
slinpf  with  the  resisting  forces  of  nature  until  held  in 
check,  when  the  limiting  wall  is  formed.  This  wall 
may  widen  and  extend  as  the  battle  progresses. 

Abscesses  are  aaite  and  chronic  (or  cold),  circti inscribed 
and  diffuse.  The}'  are  also  named  from  anatomic  indi- 
cations. 

An  acute  circnmscribed  abscess^  which  is  the  usual 
form,  presents  the  common  s}'mptoms  of  inflammation, 
with  the  heat,  pain,  and  redness  increased  in  severity. 

Chilly  sensations  and  the  various  constitutional  symp- 
toms of  inflammation  attend,  to  an  extensive  degree,  the 
formation  of  large  abscesses.  Even  small  collections  of 
pus  under  dense  tissues  may  give  rise  to  great  pain  and 
general  fever. 

The  course  of  pus-formation  is  gradual,  from  four  to 
six  days  being  usually  consumed  in  its  progress,  and 
sometimes,  when  deeply  seated,  a  much  longer  time 
elapses  before  its  presence  is  made  known.  As  the  tis- 
sues soften  the  fluid  accumulates,  a  sense  of  a  wave-like 


SUPPURATION.  29 

motion,  termed  fiuctiiation^  is  communicated  to  the 
examining  fingers,  which  is  a  characteristic  symptom  of 
accessible  abscesses.  A  thinning  of  the  overlying  sur- 
face until  it  can  be  felt  to  be  almost  ready  to  rupture  is 
tinned  po in iing.  K  pitting  on  pressure  of  cellular  tis- 
sue overlying  deep-seated  inflammation  indicates  suppu- 
ration. 

The  diagnosis  of  abscesses  is  usually  easily  made  by 
symptoms,  but  when  any  doubt  exists,  their  presence  may 
be  confirmed  by  the  needle  of  the  aspirator.  There 
should  be  no  delay  in  making  this  test  when  deep-seated 
suppuration  is  suspected,  as  no  harm  can  follow,  and  dis- 
aster in  the  shape  of  burrowing  of  the  pus,  may  be  avoided. 

An  abscess  in  the  region  of  an  artery  should  be  care- 
fully differentiated  from  a  possible  aneurysm,  the  aspir- 
ator lending  great  aid;  the  opening  of  an  abscess  in  the 
immediate  vicinity  of  large  vessels  always  calls  for  cir- 
cumspection. 

Treatment. — When  hidden  suppuration  is  suspected 
and  the  ordinary  treatment  of  inflammation  proves  in- 
efficient to  prevent  it, — that  is,  where  resolution  appears 
hopeless,— the  use  of  warm  poultices  serves  to  demon- 
strate the  collection. 

The  most  serviceable  poultices  and  those  most  readily 
procurable  are  gauze  pads  wrung  out  of  hot  antiseptic 
solutions,  and  covered  with  oiled  silk.  When  pus  is 
discovered,  it  should  at  once  be  set  free,  followed  by 
antiseptic  irrigation  and  proper  drainage.  The  walls 
may  require  scraping  with  the  curet;  free  exploration 
with  the  finger  and  probe  will  at  times  disclose  trouble- 
some sinuses,  which  may  need  to  be  cauterized. 

The  free  application  of  pure  carbolic  acid,  neutralized 
after  one  minute's  exposure  with  alcohol,  is  appropriate 
to  septic  and  gangrenous  sinuses  and  pockets. 

The  drainage  and  packing  should  be  removed  from 
incised  abscesses  once  or  twice  daily,  as  indicated  in  the 
early  treatment.  Later,  as  the  discharge  diminishes, 
the  dressing  may  remain  undisturbed  for  a  day  or  two. 


30  INFLAMMATION. 

Sloughs  and  degenerated  tissues  should  be  cut  away.  A 
solution  of  formalin,  of  a  strength  of  i:  10,000,  or  per- 
oxid  of  hydrogen,  greatly  lessens  the  discharge. 

SUMMARY. 

From  the  foregoing  we  have  determined  that  inflam- 
mation is  a  disturbance  of  the  processes  of  nutrition  due 
to  an  irritation,  pathologic  bacteria  becoming  colonized 
on  the  irritated  tissue;  that  in  those  instances  in  which 
such  colonization  is  not  effected  a  simpler  process  con- 
ducts the  physiologic  changes  of  repair.  In  both  these 
forms  of  inflammation  we  have  the  same  symptoms, 
though  different  in  degree  up  to  the  development  of  in- 
fection. We  have  seen  the  phenomena  of  inflammation 
to  be  dilatation  of  the  blood-vessels,  with  largely  in- 
creased specific  gravity  of  the  blood;  the  escape  of  the 
leukocytes  through  the  walls  of  the  veins  into  the  tissues,, 
by  which  process,  known  as  diapedesis,  the  fibrin  needed 
for  repair  is  produced.  Into  this  soil  favorable  for  col- 
onization the  soldier  leukocytes,  as  phagocytes,  are  drawn 
by  chemotaxis  to  resist  invasion. 

We  have  seen,  too,  that  this  inflammation,  if  not  so 
arrested,  tends  to  subside  by  resolution  or  to  destroy  the 
part;  that  it  is  both  acute  and  chronic,  and  that  it  affects 
the  constitution  as  well  as  the  local  part  involved;  that 
its  treatment  consists  in  encouraging  the  circulation  to 
return  to  the  normal,  and  thus  promote  the  absorption 
and  removal  of  the  products  of  inflammation. 

It  becomes  evident  that  the  termination  of  inflamma- 
tion known  as  suppuration  is  the  result  of  the  accumu- 
lation of  the  special  germ  in  sufficient  numbers  to  cause 
pus.  That  the  various  forms  of  pus  are  due  to  the  char- 
acter and*  the  virulence  of  the  infection,  rather  than  to 
other  germs.  We  see  that  pus,  when  free,  is  far  less 
damao-ino-  than  when  confined  as  an  abscess.  Abscesses 
are  indicated  by  the  same  symptoms  as  suppurative  in- 
flammation. They  require  free  opening  and  drainage 
as  soon  as  the  diagnosis  is  made. 


CHAPTER    IV. 

ULCERATION— ULCERS.— SINUS  AND  FISTULA.— THE 
PROCESSES  OF  REPAIR. 

ULCERATION— ULCERS. 

An  ulcer  is  an  infected  spot  about  which  the  surface 
skin  or  mucous  membrane  is  destroyed  by  a  slow  process 
of  molecular  or  granular  disintegration. 

The  process  of  ulceration  varies  in  extent  and  dura- 
tion according  to  the  vitality  of  the  part  and  the  viru- 
lence of  the  infection. 

The  causes  of  ulcers  may  be  looked  upon  as  both 
local  and  constitutional.  The  local  cause  may  be  trau- 
matism, particularly  wounds,  burns,  frost-bites,  etc. 
Such  injuries  usually  produce  healthy  ulcers,  which  soon 
tend  to  repair  and  cicatrization,  unless  some  constitu- 
tional dyscrasia  retard.  The  local  cause  may  also  be 
distinct  specific  infections,  as  syphilis,  etc. ;  or  perverted 
action  of  the  part  from  enfeebled  circulation,  as  in 
varicose  veins,  diseased  arteries,  or  impaired  nerves. 
These  ulcers  are  usually  unhealthy,  sluggish,  and  indo- 
lent, with  little  tendency  to  repair.  The  chief  constitu- 
tional cause  is  usually  impaired  general  nutrition,  which 
combines  with  the  local  inertia  and  maintains,  if  it  does 
not  originate,  the  morbid  process. 

Unhealthy  ulcers  are  described  as  indolent  when  they 
remain  unchanged;  phagedenic  when  they  tend  to  rapid 
and  destructive  spreadings ;  irritable  when  they  cause 
pain  ;  heniorrliagic  when  they  are  disposed  to  bleed  ; 
serpiginous  when  the)'  undermine  the  surface. 

A  healthy  ulcer  is  one  that  exhibits  a  raw  surface 
without  acute  inflammation,  and  with  but  little  secre- 
tion, whicl    is  usually  irritating.     The  edges  are  even 

31 


32 


ULCERATION — ULCERS. 


with  the  surrounding  skin  ;  a  palish  blue  line  of  cicatri- 
zation is  seen  at  the  margin,  and  it  is  covered  with  pink- 
ish granulations  over  the  field. 

The  unhealthy  ulcer  may  be  excavated,  discharging 
a  sanious  or  bloody  fluid  ;  it  may  exhibit  hardened  edges, 
or  may  burrow  beneath  the  skin.  Ulcers  may  be  of  any 
size,  even  to  the  extent  of  encircling  a  leg  or  an  arm  ; 
usually  those  of  the  benign  variety  do  not  involve  any 
but  the  tissues  of  the  skin  or  mucous  membrane. 

Healthy  ulcers  heal  by  granulation,  and  such  granula- 
tions, while   covered  with  a  pus-like  secretion,  do  not, 


Fig.  7. — Varicose  ulcer  (Warren). 


if  cleanliness  is  observed,  tend  to  produce  infection,  and 
the  micro-organisms  of  suppuration  may  even  be  absent. 
The  treatment  of  the  ulcer  will  be  controlled  wholly 
by  its  character  and  cause.  Health}^  ulcers  should  be 
cleansed  with  antiseptic  lotions  and  protected  by  gauze, 
or,  if  no  secretion  is  present,  by  rubber  tissue  under  a 
bandage  ;  such  measures  as  may  be  indicated  to  remove 
the  cause  are  to  be  employed.  Elevation  of  the  part  and 
rest  will  aid  in  regulating  the  circulation.  Support  by  a 
bandage  often  improves  the  blood-supply.  Indolent 
ulcers  should  be  stimulated — the  knife,  curet,  and  stimu- 
lating antiseptics  are  called  for. 


SINUS    AND    FISTULA.  33 

Phagedenic  and  specific  ulcers  require  cauterization 
with  nitric  acid  to  destroy  the  germ,  followed  by  repeated 
cleansing,  with  drainage  and  fresh  dressings.  The  more 
virulent  ulcers,  when  favorably  situated,  often  are  best 
excised.  In  tedious  ulcers,  otherwise  healthy,  balsam  of 
Peru  and  castor  oil — i  part  of  balsam  to  i6  parts  of  the 
oil — makes  a  valuable  dressing.  Stimulating  and  pro- 
tecting salves,  such  as  benzoated  oxid  of  zinc  ointment, 
with  0.05  per  cent,  to  0.025  P^^  cent,  ichthyol,  are 
serviceable. 

In  large  and  slowly  growing  ulcers,  notably  those  fol- 
lowing burns  and  frost-bites,  skin-grafting  on  the  healthy 
granulating  surface  is  of  great  service.  Constitutional 
supportive  treatment,  as  strychnin,  iron,  quinin,  cod- 
liver  oil,  and  similar  preparations,  often  renders  valuable 
assistance  to  the  impaired  part.  In  elderly  people  with 
extensive  ulcerations  below  the  knee  that  will  not  heal, 
amputation  without  prolonged  delay  is  indicated,  as  such 
conditions,  when  they  do  heal,  usually  recur, 

SINUS  AND  FISTULA. 

By  the  term  sinus  is  meant  a  tract  extending  from 
some  abscess  cavit}^ — due  perhaps  to  diseased  bone  or  to 
foreign  matter  buried  in  the  structures — to  the  surface. 
When  this  tract  extends  from  a  normal  cavity  it  is 
termed  a  fistula.  Usually  these  tracts  are  simply  elon- 
gated ulcers  and  may  be  due  to  similar  causes. 

A  sinus  may  be  congenital,  as  instanced  by  the  con- 
genital tracts  sometimes  encountered  in  the  neck  when, 
from  imperfect  development,  a  branchial  cyst  commu- 
nicates externally  in  this  region.  Pathologicall}'-  speak^ 
ing,  these  tracts  are  usually  either  communications  with 
ducts  or  hollow  viscera,  from  traumatism  or  unhealed 
abscesses  due  perhaps  to  diseased  bone  or  foreign  bodies 
imbedded  in  the  soft  parts. 

Abscesses  in  cellular  tissues  adjoining  the  rectum  often 
seek  an  outlet  through  that  channel,  establishing  a  fis- 
tula. If  such  abscess  opens  upon  the  skin,  the  tract 
3 


34  THE    PROCESSES    OF    REPATR. 

should  be  called  a  sinus.  If,  however,  it  involves  the 
rectum, — a  normal  cavity, — either  with  or  without  ex- 
ternal opening,  it  is  called  a  fistula.  The  cause  of  these 
abscesses  may  at  times  be  inflammatory,  but  it  is  more 
commonly  tubercular. 

The  treatment  of  sinus  is  determined  by  the  cause. 
The  course  and  direction  of  the  tract  must  be  ascertained 
with  gentle  manipulation  by  the  probe.  If  it  is  due  to 
disease  of  the  bone  or  to  a  foreign  body,  this  must  be 
removed.  If  an  old,  unhealthy,  granulating  sinus  be 
freely  cureted,  cauterized  with  pure  carbolic  acid,  and 
packed  with  gauze,  if  no  foreign  body  be  present  it  will 
often  heal.  A  chronic  sinus  may  be  extirpated  if  no 
foreign  body  be  left.  This  treatment  is  especially  appro- 
priate in  the  tubercular  form. 

Fistula  due  to  traumatism  will  often  heal  if  the  part 
is  placed  in  .a  position  favorable  for  approximation  of 
the  edges.  In  some  cases  repair  will  obtain  if  the  edges 
of  the  fistula  are  freshened  and  sutured. 

When  fistula  exists  for  months  without  improvement, 
the  probability  of  a  resulting  spontaneous  cure  becomes 
lessened.  Fistula  of  the  salivary  glands  often  baffles 
every  eflfort  at  repair.  It  is  here  that  careful  dissection 
of  the  tract,  with  skilful  suturing  of  the  fistula,  will 
sometimes  result  in  a  cure.  The  same  is  true  of  intes- 
tinal fistula  through  the  abdominal  wall,  and  of  gastric 
or  stomach  fistula. 

THE  PROCESSES  OF  REPAIR. 

The  processes  of  repair  represent  changes  which  sim- 
ulate normal  growth  going  on  in  healthy  wounds.  The 
essential  of  this  repair  is  the  renewed  activity  of  quies- 
cent cells  of  the  tissues.  These  cells,  which  in  the  em- 
bryonic stage  by  proliferation  developed  the  organism 
and  then  rested,  are  now  required  to  effect  the  repair  of 
damage  done  to  their  perfected  work.  It  is  necessary  to 
understand  that  each  damaged  tissue  repairs  its  own  loss: 
thus  bone  is  replaced  by  bone,  skin  by  skin,  each  struc- 


THE    PROCESSES    OF    REPAIR.  35 

ture  being  restored  by  the  growth  or  proliferation  of  its 
own  distinct  cells. 

After  the  hemorrhage  of  a  recent  wound  has  ceased 
and  the  edges  of  the  wound  are  approximated,  the  first 
steps  of  repair  are  those  of  physiologic  inflammation. 
Upon  these  products  of  inflammation  the  proliferating 
connective-tissue  cells  feed  until  lost  tissue  is  replaced. 
If  the  approximation  is  close  and  accurate,  little  tissue 
is  regenerated.  If  a  considerable  gap  or  loss  is  present, 
the  process  is  slow,  because  considerable  tissue  must  be 
regenerated.  The  first  is  called  union  hy  Jirst  intention; 
the  second,  union  by  granulation.  The  process  is  not, 
however,  the  same.  Usually  in  union  by  first  intention 
phagocytes  are  able  to  hold  in  check  and  destroy  the 
germs. 

Cell-proliferation  is  accomplished  by  division  of  the 
cells  in  two  ways:  Direct  division  of  the  nucleus  and 
protoplasm  of  the  cell  and  the  formation  of  two  cells  by 
a  splitting  process;  or  a  gradual  process  of  fibrillation  of 
the  nucleus^  around  which  rearrangement  the  protoplasm 
divides,  thus  forming  other  cells.  This  latter  process  is 
known  as  karyokinesis,  and  is  the  essential  of  most  re- 
pair. Many  of  these  newly  formed  cells,  called  fibro- 
blasts, are  not  fixed,  and,  together  with  other  so-called 
wandering  cells,  the  origin  of  which  is  not  wholly  clear, 
become  entangled  in  the  trabecula  of  the  new  and  pre- 
existing tissue,  and  are  organized  along  with  the  fixed 
cells,  thus  contributing  greatly  to  repair. 

In  the  granulation  form  we  have  a  process  which 
usually — not  invariably — succeeds  suppuration  and  de- 
structive conditions.  Here,  after  nature  has  overcome 
the  germs,  the  cells  in  the  healthy  tissue  begin  to  grow, 
and,  by  karyokinesis,  there  are  formed  granulations — 
minute  and  innumerable  bodies  in  which  are  seen 
miniature  blood-vessels.  These  grranulations  erow  and 
become  organized  in  the  deeper  layers,  and  thus  the 
wound  is  gradually  filled  in. 

Althouo;h  ofranulations  are  not  seen  in  union  bv  first 


7,6  THE    PROCESSES    OF    REPAIR. 

intention,  and  in  fact  do  not  usually  form,  yet  the  same 
principles  are  exhibited  in  the  cell-proliferation  of  repair. 
In  both  instances  this  new  tissue,  although  resembling 
that  lost,  is  never  strictly  the  same,  nor  does  it  ever 
completely  resume  the  function  of  the  old.  This  is 
more  distinctly  seen  in  wounds  of  organs  of  special 
sense,  particularly  the  eye  and  ear,  which,  if  severely 
damaged,  are  never  fully  restored  to  function. 

Scar  tissue  is  never  so  highly  organized  or  nourished 
as  normal  tissue,  and  is  more  prone  to  ulceration  and  even 
malignancy.  It  also  tends  to  contract,  and  when  occu- 
pying a  considerable  surface,  may  cause  great  deformity 
by  firm  contraction. 

Granulation  tissue  should  jBll  in  the  center  of  the 
wound  as  it  contracts,  about  the  same  time  that  its 
edges  cicatrize.  Should  it  happen  that  the  granulations 
rise  above  the  edges  (so-called  exuberant  granulations, 
or  proud  flesh),  they  must  be  destroyed,  either  by  the 
knife  or,  preferably,  by  the  caustic,  repeating  the  appli- 
cation until  the  wound  cicatrizes. 

It  is  to  be  borne  in  mind,  then,  that  in  repair  union  by 
first  intention  is  the  immediate  process  of  physiologic  in- 
flammation, while  in  granulation  it  is  physiologic  inflam- 
mation succeeding  pathologic,  and  later  pursuing  the 
same  steps  as  in  the  similar  condition — filling  in  the 
wider  gaps  by  the  same,  but  slower,  process,  and  often 
being  delayed  and  interrupted  by  the  battle  between  the 
germs  and  the  phagocytes.  It  should  be  remembered, 
too,  that  though  tissues  always  reproduce  like  tissues, 
the  so-called  regenerated  tissue  is  never  identical  in 
whole  with  the  original,  cicatricial  tissue  ever  being 
imperfect. 

Repair  of  gross  losses  of  limbs  or  organs  is  impossible, 
because  of  the  absence  of  needed  tissue-cells,  and  because 
the  substance  to  support  granulation  cells  is  not  obtain- 
able. For  this  last  reason  great  losses  of  tissue,  even 
in  the  trunk  or  muscles,  fail  of  restoration  ;  and  for 
similar  reasons  nature  presses  forward  in  her  efibrts  at 


SUMMARY.  37 

restoration  until  her  stores  are  exhausted.  Plastic  sur- 
gery— skin-grafting  and  tissue  transplanting — is  fre- 
quently employed  to  stimulate  suspended  granulation 
and  bridge  over  great  losses  which  at  first  appeared  to  be 

permanent. 

SUMMARY. 

We  learn,  from  the  foregoing,  that  pus  is  the  result  of 
germs  of  suppuration,  a  quarter  of  a  million  being  re- 
quired to  form  a  small  abscess  ;  that  it  is  the  result  of 
infection  of  the  products  of  inflammation  ;  that  it  does 
damage  chiefly  from  being  confined,  and  hence  demands 
free  drainage.  An  accumulation  of  pus,  we  learn,  is 
called  an  abscess,  named  acute  or  chronic  (or  cold)  ;  that 
acute  abscesses  give  rise  to  the  same  symptoms  as  acute 
inflammation,  except  that  there  is  more  pain  and  that 
an  added  symptom  of  fluctuation,  indicating  fluid,  is 
present.  We  also  find  that  the  treatment  of  acute  ab- 
scesses is  by  free  incision,  with  antiseptic  irrigation  and 
drainage  ;  while  that  of  cold  abscesses  is  less  active. 

We  find  an  ulcer  to  be  practically  an  uncovered  abscess, 
usually  chronic,  due  to  local  and  constitutional  innutri- 
tion. Ulcers  bear  self-defining  titles,  the  most  import- 
ant of  which  are  healthy  and  tinJiealthy.  Their  treat- 
ment requires  the  removal  of  the  cause  and  stimulation 
for  repair. 

We  learn  that  both  sinus  and  fistula  are  practically 
elongated  ulcerated  surfaces,  although  communicating 
with  cavities  and  conveying  discharges. 

Repair,  it  is  seen,  is  accomxplished  by  renewed  activity 
of  original  cells,  which  produce  new  tissue  in  place  of 
that  lost,  and  in  the  same  manner  as  that  lost  was  orig- 
inally produced.  That  cells  of  one  kind  of  tissue — as 
bone  or  skin — invariably  produce  their  kind.  That  this 
growth  is  chiefly  accomplished  by  indirect  cell-division, 
called  karyokinesis.  That  the  outgrowth  of  this  cell- 
proliferation  is  granulations,  which  later  become  organ- 
ized into  normal  tissue  to  replace  the  lost,  though  never 
absolutely  identical  with  the  adjacent  original  structures. 


CHAPTER  V. 
GANGRENE THROMBOSIS  AND  EMBOLISM. 

GANGRENE. 

By  the  term  gangrene  is  meant  death  of  a  mass  of  the 
soft  parts,  in  contradistinction  to  the  molecular  death  in 
ulceration.  The  death  of  bone  masses  is  termed  necrosis. 
Putrefaction^  mortijication^  and  slough  are  terms  applied 
to  the  gangrenous  process,  and  usually  indicate  the  extent 
of  damage. 

The  causes  of  gangrene,  like  those  of  ulceration,  are 
chiefly  interference  with  the  circulation,  either  by  shut- 
ting off  the  arterial  current  or  by  the  arrest  and  stagna- 
tion of  the  blood  in  the  veins.  This  arrest  is  due  to 
rupture  of  the  vessels  or  to  their  obstruction  by  constric- 
tion or  an  embolus  ;  in  the  venous  current  it  is  due  to 
constriction  of,  or  pressure  upon,  a  large  venous  trunk. 

We  recognize  two  forms  of  gangrene — dry  and  moist. 

Dry  gangrene  is  due  chiefly  to  gradual  interference 
with  the  arterial  supply,  seen  usually  in  elderly  persons, 
and  is  termed  "senile  gangrene."  It  is  the  result  of 
chronic  inflammation  of  the  inner  arterial  wall,  usually 
an  atheromatous  degeneration.  Senile  gangrene  gener- 
ally begins  in  the  toes  or  foot,  at  times  in  the  fingers, 
where  the  blood-supply  is  always  feeblest. 

Symptoms — Often  after  a  bruise  or  slight  abrasion  the 
wound  fails  to  heal,  becomes  congested,  blackened,  dry, 
and  mummified.  There  is  usually  a  burning  pain,  and 
sometimes  an  offensive  odor  is  present  early.  At  the 
base  of  this  discoloration  there  is  a  line  sharply  marking 
off  the  disease.  This  line  gradually  extends  until  per- 
haps the  whole  foot  or  even  the  entire  limb  may  be  in- 
volved.    There  are  evidences  of  general    sepsis.     The 

38 


TREATMENT  OF  MOIST  GANGRENE.  39 

calcareous  condition  of  the  vessels  may  be  judged  of 
when  such  indurations  and  nodulations  are  felt  on  the 
radial  arteries. 

In  individuals  affected  with  diabetes  mellitus — sugar 
in  the  urine — a  similar  gangrene  is  often  seen,  even  in 
younger  persons,  without  atheromatous  changes  in  the 
vessels  being  indicated.  Gangrenous  ulcers  in  young 
adults  should  always  suggest  an  examination  of  the  urine 
for  sugar. 

Moist  gangrene  is  caused  by  a  sudden  destruction  of 
a  large  artery  of  an  extremity,  or  sometimes  by  arrest  of 
the  circulation  in  two  or  more  large  veins.  Extensive 
contusion  and  laceration  of  the  tissues  at  the  time  of 
injury  favor  infection  and  sloughing,  the  damage  to 
the  circulation  inducing  gangrene  of  the  moist  variety. 
Bed-sores,  frost-bites,  and  burns  may  cause  local  moist 
gangrene.  When  infection  sets  up  in  any  form,  the 
gangrene  may  spread  rapidly  in  a  few  days,  involving 
even  the  entire  limb. 

Symptoms — The  characteristic  symptom  of  moist 
gangrene  is  the  dark  purplish  discoloration  seen  on 
the  surface,  accompanied  by  blebs  or  blisters,  and  pro- 
ducing the  offensive  odor  of  decomposition.  Septic 
products  imprisoned  in  these  processes  are  absorbed, 
and  grave  constitutional  symptoms — high  temperature 
and  rapid  pulse — characterizing  blood-poisoning  are 
set  up. 

Pain  is  not  present  in  gangrene /<?r  se.  All  these  con- 
ditions represent  a  faulty  circulation  of  the  blood,  to 
which  is  added  an  infection.  When  the  fault  lies  in  the 
smaller  arteries,  the  effects  are  slowly  produced  and  less 
impression  is  made  on  the  constitution.  When,  how- 
ever, a  large  extent  of  tissue  is  suddenly  deprived  of 
nutrition  and  the  evaporation  of  the  retained  fluids 
becomes  impossible,  rapid  decomposition  and  infection 
set  in. 

Treatment. — The  preventive  treatment  of  gangrene 
consists  of  maintaining  the  equilibrium  of  the  circula- 


40  GANGRENE. 

tion,  the  relief  of  tension  and  constriction  when  discov- 
ered, and  the  favoring  of  the  venous  current  by  elevation 
of  the  part.  Warmth  to  the  part  promotes  the  flow  of 
blood,  and  gentle  manipulation  is  also  of  service.  In 
the  aged,  careful  attention  should  be  given  to  sores  on 
the  extremities  lest  they  become  the  seat  of  senile  gan- 
grene. 

Operative  measures  promise  little  in  the  constitutional 
condition  which  produces  senile  gangrene,  and  unless 
septic  processes  are  progressing  and  become  dangerous, 
it  is  better  to  wait  until  the  line  of  demarcation  appears. 
Careful  covering  and  protection  will  give  better  results 
in  ordinary  cases.  If  infection  of  a  threatening  character 
appears,  amputation  at  a  good  distance  from  the  point 
of  the  disease  may  be  proposed. 

In  ordinary  moist  gangrene  it  is  well  to  await  the 
line  of  demarcation,  especially  in  the  superficial  forms. 
When  spreading  and  infective,  prompt  amputation  at  a 
distance  from  the  point  is  the  only  indication.  While 
awaiting  changes  in  moist  gangrene  it  is  well  to  keep 
the  parts  enveloped  in  dressings  saturated  with  solution 
of  potassium-permanganate,  5  grains  to  a  pint  of  water, 
which  diminishes  both  odor  and  infection.  Stimulants 
and  supportive  treatment  are  required. 

If  an  amputation  is  deemed  proper,  it  should  be  done 
well  above  the  diseased  tissue.  In  senile  gangrene  am- 
putation should  not  only  be  high  above  the  line  of 
demarcation,  but  even  above  the  next  articulation.  It 
is  impossible  to  tell  where  the  obstruction  in  the  artery 
is  situated,  and  unless  the  amputation  is  made  above  the 
obstruction,  the  process  will  continue  to  spread.  Even 
under  the  most  favorable  circumstances  amputation  under 
these  conditions  is  often  a  disappointment,  and  the  shock, 
added  to  the  previous  depression,  either  produces  imme- 
diate death  or  hastens  the  fatal  termination. 

Sloughs  and  bed-sores  should  be  allowed  to  separate 
themselves,  at  least  partially,  under  antiseptic  dressings. 
These  dressings  should  be  saturated,  preferably  with  the 


SUMMARY.  41 

potassium  permanganate  solution,  5  to  10  grains  to  a 
pint  of  water.  This  is  a  mild  antiseptic,  but  a  very  effi- 
cient deodorant.  Loose  portions  of  slough  should  be 
separated  with  the  scissors  and  forceps. 

THROMBOSIS   AND   EMBOLISM. 

Thrombosis. — By  thrombosis  is  meant  the  formation 
of  a  blood-ciot  in  a  vein.  This  clot,  or  thrombus,  may 
wholly  occlude  the  vessel,  or  may  be  adherent  to  the 
walls,  with  the  stream  passing  by  it.  The  clot  is  almost 
always  the  result  of  an  infection  of  the  vein-wall,  or  else 
of  an  injury. 

Usually  the  infection  causes  softening  of  the  thrombus 
and  portions  of  it  are  washed  away,  either  to  lodge  in 
the  vein  and  form  another  thrombus,  or,  as  is  more  com- 
mon, to  pass  through  the  heart  and  be  sent  into  the 
lungs,  producing  pulmonary  embolism,  often  fatal.  Or 
the  pieces  of  thrombus  may  pass  through  the  lungs 
and  find  their  way  into  the  arterial  circulation,  brain, 
kidneys,  and  other  viscera. 

Bmbolism. — The  detached  clot  is  termed  an  embolus. 
This  clot  is  likely  to  be  lodged  in  some  vessel  and  occlude 
it.  If  infected,  as  in  pyemia,  abscesses  will  form  ;  if  it 
be  larsre  enough  to  obstruct  an  arterv  of  considerable 
size,  gangrene  may  take  place.  Such  clots,  when  ar- 
rested in  the  brain,  are  likely  to  produce  embolic  apo- 
plexy; in  other  viscera,  infection  and  abscess  result. 

Thrombi,  though  practically  seen  only  in  veins,  may 
form  in  a  diseased  heart  or  in  the  terminals  of  damaged 
arteries.  In  the  former  situation  they  are  most  danger- 
ous because  they  are  soon  detached  and  carried  into  the 
arterial  circulation.     In  the  arteries  they  may  produce 

gangrene. 

SUMMARY. 

By  gangrene  we  understand  a  process  of  mass  decom- 
position or  mortification,  due  to  interference  with  the 
blood-supply.  When  the  interference  is  abrupt,  moist 
decomposition  takes  place  ;  when  gradual  and  limited. 


42  THROMBOSIS    AND    EMBOLISM. 

a  dry  mummification  results.  Sepsis  sets  up  early  in  the 
moist  form,  and  late  in  the  dry.  A  line  of  demarcation 
should  be  awaited  before  amputation,  unless  sepsis 
threatens  life.  Sugar  in  the  urine  is  to  be  suspected  in 
idiopathic  gangrene  in  young  persons.  The  treatment 
is  protective,  consisting  in  enveloping  the  part  in  cotton 
batting.  When  present,  antiseptic  and  deodorizing  lo- 
tions, with  quinin  and  stimulants,  should  be  used. 
Operative  measures  are  indicated  in  sepsis. 

By  thrombosis  is  meant  a  fixed  clot  in  a  vein.  If  this 
clot  be  detached  and  carried  into  some  smaller  vessel, 
usually  an  artery,  it  is  termed  an  embolus.  Such  clots 
are  generally  infected,  and  when  detached,  carry  infec- 
tion into  remote  situations. 


CHAPTER    VI. 

AUTO=INFECTION.  —  SURGICAL  FEVER.  —  SAPREMIA 
AND  SEPTICEMIA. 

AUTO=INFECTION. 

Though  it  is  distinctly  a  part  of  physiology  to  explain 
'what  is  meant  by  elimination  and  the  importance  of 
getting  rid  of  the  many  poisons  hourly  created  in  the 
organism  through  the  skin,  kidneys,  bowel,  and  other 
emunctories,  yet  it  is  a  prominent  feature  of  the  daily 
practice  of  the  surgeon  to  look  after  this  elimination, 
and  it  is  well  to  be  reminded  of  the  importance  of  these 
functions. 

The  function  of  respiration,  as  well  as  that  of  perspi- 
ration, does  not  usually  require  special  attention,  though 
both  are  powerful  auxiliaries  of  the  direct  excretory 
organs.  However,  they  usually  continue  to  act  without 
artificial  aid. 

Auto-intoxication  from  retained  products  which  should 
have  been  eliminated  by  the  kidneys  is  well  known  to  be 
a  promptly  destructive  agent.  A  slower  process  of  poi- 
soning goes  on  as  a  result  of  imperfect  functioning  of  the 
liver,  and  perhaps  a  still  tardier  but  none  the  less  depress- 
ing poisoning  results  from  improper  elimination  by  the 
intestines. 

With  a  little  care,  in  the  vast  majority  of  cases  it  is 
not  difficult  almost  wholly  to  prevent  these  evils  by  the 
simplest  attention  and  the  administration  of  standard 
medicines.  Of  course,  the  existence  of  structural  disease 
may  render  any  treatment  futile,  but  it  too  often  hap- 
pens that  sluggish  intestinal  action,  engorged  liver,  or 
overburdened  kidneys,  without  structural  changes  in 
these  organs,  may  impair  the  appetite  and  disturb  the 

43 


44  SURGICAL    FEVER. 

rest  of  the  patient,  rendering  him  dull  and  stupid,  and 
constantly  retard  his  capability  for  resistance  or  improve- 
ment. 

In  all  operations  of  election  careful  preparation  must 
be  made  to  secure  the  cooperation  of  all  these  functions, 
and  when,  as  in  emergencies,  sufficient'  time  has  not 
been  allowed  for  previous  attention,  more  energetic  and 
persevering  measures  of  treatment  must  be  kept  in  mind. 

SURGICAL  FEVER. 

In  spite  of  the  measures  taken  to  secure  asepsis  after 
operations  of  election,  and,  so  far  as  possible,  those  of 
necessity  and  accident,  but  few  large  wounds  heal 
without  producing  a  rise  in  temperature.  This  rise, 
which  is  not,  of  necessity,  a  part  of  any  infection,  is 
usually  noticed  on  the  evening  of  the  first  day,  accom- 
panied by  a  corresponding  increase  in  the  rapidity  of 
the  pulse.  Such  rise  depends  largely  upon  the  severity 
of  the  shock,  and  may  at  times  run  as  high  as  103°  F. 
or  even  higher,  although  usually  it  is  not  above  100.5°  ^-5 
the  pulse  generally  averaging  from  80  to  90.  Slight 
malaise,  headache,  coated  tongue,  in  fact,  the  ordinary 
indications  of  mild  inflammation,  are  present,  and  per- 
sist usually  for  from  twenty-four  to  thirty-six  hours. 

The  height  of  temperature  and  the  rapidity  of  the 
pulse,  as  well  as  the  corresponding  symptoms,  are  usually 
present  on  the  evening  of  the  second  day.  If  fever  per- 
sists or  is  increased  in  severity  on  the  morning  of  the 
third  day,  some  local  cause  is  usually  at  fault  and  a 
change  of  dressing  is  indicated. 

It  is  true  that  such  fever  may  continue  during  the 
aseptic  healing  of  large  wounds  when  much  effusion 
occurs  and  repair  is  slow.  Local  symptoms  about  the 
wound,  with  throbbing,  redness  and  pain,  or  sweats,  will 
indicate  the  presence  of  pus  and  sepsis,  showing  that  the 
fever  is  no  longer  a  reparative,  but  a  destructive,  one. 

The  treatment  of   aseptic   fever   consists  chiefly  in 


SAPREMIA.  45 

attention  to  the  emunctories  (noted  under  Auto-infection) 
and  such  symptomatic  indications  as  may  arise. 

When  the  septic  processes  are  established  one  of  the 
three  forms  in  some  degree  of  severity  is  present — sapre- 
mia,  septicemia,  or  pyemia. 

SAPREMIA. 

While  it  is  well  known  that  all  the  so-called  blood 
poisons  are  generated  by  the  products  of  pyogenic  organ- 
isms, yet  these  products  act  differently  in  each  variety: 
not  always  so  distinctly  as  clearly  to  indicate,  beyond 
question,  the  phenomena,  but  to  a  degree  characteristic 
enough  to  give  each  variety  its  name. 

By  sapremia  is  to  be  understood  the  action  of  the 
germs  of  putrefaction, — the  saprophytic  bacteria, — in 
the  presence  of  which  the  ptomains  are  formed.  The 
ideal  causative  agent  of  sapremia  is  found  in  the  retained 
afterbirth  in  the  puerperal  state,  whether  following  abor- 
tion or  full-term  delivery.  Any  decomposing  product 
favoring  absorption  is  a  focus  for  the  infection,  acute 
spreading  gangrene  and  infectious  sloughs  often  offering 
a  starting-point.  If  not  promptly  removed,  however, 
the  infection  is  soon  generally  distributed  throughout  the 
entire  system,  and  septic  intoxication  or  septicemia  is 
the  result. 

Death  can  rarely  be  referred  to  the  sapremia  alone,  for 
it  does  not  follow  the  infection  closely,  the  course  almost 
always  being  determined  by  the  general  infection  present, 
although  the  action  of  ptomains  is  similar  to  that  of 
other  alkaloidal  poisoning — a  constantly  repeated  dosage 
until  the  source  is  removed. 

The  symptoms  of  sapremia  are  those  of  infection 
generally.  Not  rarely  the  first  symptom  is  a  chill,  with 
high  temperature  and  a  rapid  pulse — perhaps  dispropor- 
tionately rapid.  Sometimes  foreshadowing  trouble,  the 
chill  is  preceded  by  a  rise  in  temperature  and  quickened 
pulse,  with  nausea,  vomiting,  and  often  diarrhea.  After 
the  chill  the  temperature  usually  returns  to  the  normal, 


46  SEPTICEMIA. 

but  the  pulse  remains  rapid — in  severe  infections  num- 
bering above  lOO.  If  the  decomposing  product  can  be 
removed  before  a  septic  condition  is  set  up  in  the  blood, 
recovery  will  be  very  prompt  and  complete,  the  chills 
will  not  return,  and  the  pulse  will  soon  become  normal. 
If,  however,  there  is  any  delay,  septicemia  becomes 
established. 

The  prognosis  in  sapremia  is  better  than  in  either  of 
the  other  septic  processes,  because  if  the  putrefying  mass 
is  accessible — as  it  often  is — and  can  be  promptly  re- 
moved, a  cure  can  usually  be  effected.  In  those  instances 
in  which  the  focus  is  not  promptly  eradicated,  the  course 
tends  toward  septicemia  and  death. 

The  treatment  is  both  local  and  constitutional. 
When  in  any  way  the  cause  can  be  removed  early,  this 
step  is  imperative.  If  it  is  delayed  until  general  infec- 
tion occurs,  it  will  most  likely  be  useless,  although  even 
then,  if  an  operation  be  not  productive  of  too  great  a 
shock,  it  should  be  done. 

Strong   local    antiseptics   should    be   applied    to    the 

wound.      Constitutionally,  aside  from  free  purgation  and 

stimulation,  the  treatment  is  that  to  be  described  for 

septicemia. 

SEPTICEMIA. 

In  this  variety  the  general  infection  may  follow  a  sap- 
remia in  which  the  poison  has  been  distributed  through- 
out the  system,  while  the  original  focus  continues  to 
supply  it,  or  before  its  successful  removal.  However,  it 
not  infrequently  follows  a  very  simple  wound,  one  in 
which  there  occurs  little  local  disturbance. 

Slight  wounds  inflicted  in  conducting  postmortems 
and  in  dissecting,  as  well  as  septic  operations  of  seeming 
slight  importance,  are  occasional  sources  of  fatal  septi- 
cemia, without  even  producing  serious  local  distress. 

The  symptoms  of  septicemia,  like  those  of  sapremia, 
may  be  sudden  or  gradual.  Usually  a  chill  either  an- 
nounces the  infection  or  follows  the  slight  fever  and 
malaise  of  a  day  or  two  after  infection.     Sometimes  this 


SEPTICEMIA.  47 

period  of  inoculation  is  even  considerably  longer,  but 
usually  by  the  third  or  fourth  day  after  infection  severe 
symptoms  are  manifested.  In  the  less  violent  infections 
elevation  of  temperature  occurs,  with  slight  rigors  and  a 
correspondingly  rapid  pulse,  the  case  being  marked  for 
a  week  or  so  by  a  degree  of  depression  and  prostration 
out  of  all  proportion  to  the  other  symptoms.  A  grave 
condition  is  indicated  by  a  severe  chill,  with  high  tem- 
perature and  rapid  pulse,  succeeded  by  sweats. 

The  fever  is  characterized  by  remissions,  but  the  pulse 
usually  remains  constantly  above  lOO.  Commonly  the 
chill  does  not  recur  more  than  two  or  three  times,  but 
chilly  sensations  and  cold  feet  and  hands  precede  a  rise 
in  temperature. 

"When  the  infection  is  in  the  extremities,  the  lymphatic 
tracts  are  often  outlined  by  a  red  line,  exhibiting  tender- 
ness on  pressure.  Later,  in  the  milder  forms,  lymph- 
nodes,  which  later  suppurate,  form  in  the  course  of  these 
channels.  These  nodes  are  not  only  discolored,  but  prior 
to  suppuration  are  painful,  and  although  deeply  seated, 
may  cause  great  suffering.  Although  originally  the 
septic  processes  begin  in  the  wound,  the  poisons  grow 
and  multiply  everywhere  in  the  system  after  the  disease 
becomes  general,  and  the  pulse  becomes  more  rapid  and 
grows  weaker.  Toward  the  close  of  the  disease  the  teni.- 
perature  may  even  remain  low,  with  occasional  exacer- 
bation. The  author  has  never  known  recovery  to  fol- 
low a  case  of  septicemia  in  which  diarrhea,  with  invol- 
untary evacuations,  was  a  symptom. 

Death  in  the  more  acute  and  violent  form  usually 
comes  on  within  ten  days.  Severe  cases  may  last  for 
two  weeks  or  more.  In  the  milder  form  convalescence 
may  be  established  after  two  weeks.  The  approach  of 
death  is  usually  announced  by  stupor.  The  mind  be- 
comes sluggish,  and  a  restless  delirium  gives  way  to  dul- 
ness  and  unconsciousness.  Jaundice  and  a  dusky  color 
of  the  skin  indicate  o-rave  blood  chanees. 


48  SEPTICEMIA. 

TREATMENT. 

If  the  case  be  seen  early,  free  drainage  and  cauteriza- 
tion with  pure  carbolic  acid,  or  even  the  actual  cautery, 
are  to  be  promptly  employed,  followed  by  energetic  local 
disinfection.  If  the  case  is  one  occurring  from  infection 
from  a  large  cavity  or  wound,  the  drainage,  irrigation, 
and  disinfection  without  the  cautery  is  to  be  the  line  of 
treatment.  Free  elimination  by  the  bowels  and  kidneys 
is  to  be  obtained,  although  the  danger  of  diarrhea  in  the 
later  stages  is  to  be  borne  in  mind.  Should  the  diarrhea 
become  troublesome,  charcoal  and  pepsin  are  to  be  ad- 
ministered. Hypodermic  injections  of  strychnin,  qui- 
nin,  whisky,  and  other  stimulants,  as  well  as  judicious 
feeding,  are  called  for. 

The  antistreptococcic  serum  has  in  a  small  proportion 
of  ^  cases  been  reported  as  of  great  service.  In  the  obser- 
vation and  experience  of  the  author  it  has  effected  no 
permanent  good.  Efforts  at  supportive  treatment  should 
not  be  abandoned  even  in  seemingly  hopeless  cases,  as 
recovery,  following  apparently  inevitable  death,  is  at 
times  seen, 

SUMMARY. 

By  auto-infection  or  acute  intoxication  is  meant  ab- 
sorption, either  in  a  new  wound  or  in  the  general  circu- 
latory tracts,  of  poisons  generated  in  the  body  itself  or 
ingrafted  upon  it  in  some  one  spot.  The  absorption  of 
urine,  bile,  or  the  contents  of  the  bowels,  as  well  as 
inoculation  of  a  second  chancroid  from  the  primary 
sore,  are  illustrations.  Hence,  cleanliness  and  care  of 
the  emunctories  are  essential. 

Surgical  fever^  not  septic,  is  the  reaction  from  the 
shock  of  the  wound,  as  well  as  the  struggle  of  the  leuko- 
cytes with  bacteria.  Usually  it  is  past  in  forty-eight 
hours,  but  it  may  continue  of  a  low  grade  and  yet  not 
become  septic  for  a  week  or  more.  Symptomatic  treat- 
ment alone  is  required. 

Septic  processes  occur  in  the  form  of  sapremia,  which 


SUMMARY. 


49 


is  ptomain-poisoning;  septicemia,  which  is  the  result  of 
toxins  and  infective  products  in  the  general  circulation, 
both  through  the  Ivmphatics  and  blood-vessels — or  pve- 
mia,  which  is  the  direct  transmission  of  pus  into  the 
vessels. 

The  symptoms  in  the  first  two  are  ver\-  similar,  the 
history  ser\-ing  to  make  the  diagnosis,  which  is  an  im- 
portant step,  as  the  cause  of  sapremia  is  often  suscept- 
ible of  removal.  The  general  treatment  consists  of 
drainage,  irrigation,  and  supportive  measures.  Anti- 
streptococcic serum  is  advocated  by  good  authority. 


CHAPTER  VII. 

PYEMIA ERYSIPELAS.— ACTINOMYCOSIS. 

PYEMIA. 

Pyemia  is  the  result  of  a  septic  infection  of  the  veins, 
causing  a  phlebitis,  then  a  thrombosis,  of  which  clots, 
particles,  or  emboli  are  carried  to  the  heart  and  thence 
distributed  throughout  the  body. 

Pus  is  not  found  freely  circulating  in  the  blood,  but 
the  germs  of  suppuration  are  carried  in  these  emboli. 
When  the  emboli  lodge,  an  abscess,  known  as  a  metas- 
tatic abscess,  forms;  ptomains  and  other  septic  products 
are  carried  in  a  similar  manner.  Pyemia  usually  fol- 
lows a  septicemia,  even  the  mild  variety. 

The  symptoms  of  pyemia  will  not,  it  is  clear,  occur 
until  the  septic  products  lodged  in  the  infected  veins 
have  undergone  softening  and  become  developed  and 
transported  to  a  new  location.  The  primary  chill  of 
pyemia  is  usually  seen  about  the  tenth  day  after  infection. 
The  initial  chill,  which  is  generally  severe,  may  come 
on  without  warning,  although  usually  in  an  otherwise 
healthy  wound,  some  fever  and  acceleration  of  pulse  will 
be  noted,  A  temperature  of  103°  to  105°  F.  follows  the 
chill,  succeeded  by  exhausting  sweats;  at  the  decline  of 
the  fever  there  is  a  return  to  perhaps  nearly  the  normal 
temperature,  followed  by  a  rise  again  in  a  short  time. 

The  pulse  continues  to  be  rapid,  and  during  the  chill 
may  reach  150.  It  is  commonly  stated  that  another 
chill,  following  within  twenty-four  hours,  indicates  the 
location  of  another  embolus,  yet  it  is  highly  probable 
that  one  point  of  infection  may  account  for  repeated 
chills.  Frequently  these  chills  vary  in  severity,  but 
toward  the  close  of  the  disease  the  shock  may  become 

50 


PYEMIA.  51 

profound  during. the  chill,  and  death  immediately  follow. 
The  mind  is  usually  clear,  except  at  the  time  of  the 
shock,  when  mild  delirium  may  be  present. 

Embarrassed  respiration,  frothy  and  blood-stained 
serum,  with  harassing  cough  indicate  that  the  emboli 
have  lodged  in  the  lungs.  Metastatic  abscesses  may 
appear  in  the  joints. 

Pain,  tenderness,  and  jaundice  indicate  that  the  em- 
boli have  invaded  the  liver.  These  metastatic  abscesses 
may  be  very  small,  but  at  times  large  abscesses  present 
and  are  opened.  Later  the  shock  of  the  chills  is  more 
depressing,  the  pulse  is  feebler,  the  lungs  are  more  en- 
gorged, the  emaciation  is  marked,  the  bowels  are  loose 
and  uncontrollable,  the  skin  is  dusky  and  yellowish,  the 
urine  scanty  and  dark  red,  and  the  exhaustion  progres- 
sive. 

Death  generally  occurs  in  from  one  to  two  weeks,  but 
four  or  six  weeks  may  elapse,  even  in  severe  cases,  be- 
fore the  fatal  termination  ensues.  The  progressive  char- 
acter of  the  affection  must  be  kept  in  mind,  lest  the 
clear  intelligence,  the  strong  though  quickened  pulse, 
and  the  periodic  defervescence  of  the  fever  may  en- 
courage false  hope.  On  postmortem  examination,  in- 
numerable small  embolic  abscesses  are  found  in  the 
lungs,  liver,  spleen,  parotid  gland,  and  perhaps  in  some 
of  the  joints. 

Acute  pyemia  is,  from  its  inception,  practically  a  prog- 
ress to  the  grave.  In  the  milder  chronic  forms  recov- 
ery is  possible,  but  rare.  The  disease  is  far  less  fre- 
quent than  formerly,  since  the  almost  imiversal  em- 
plovment  of  aseptic  and  antiseptic  measures. 

Treatment. — When  possible,  remove  the  cause,  and 
if  the  thrombotic  foci  can  be  located,  which  in  acute 
general  pyemia  is  generally  impossible,  they  should  be 
well  cleared  out.  Drainage  and  irrigation  of  abscesses, 
when  located,  are  indicated,  but  promise  little. 

General  constitutional  treatment  is  practically  the 
same  as  in  septicemia.     Nourishment,  stimulation,  and 


52  ERYSIPELAS. 

rest   constitute   the   general    measures ;    strychnin    and 
whisky  are  the  essential  stimulants. 


ERYSIPELAS. 

Erysipelas  is  an  acute  infection  of  the  skin  or  mucous 
membrane  and  the  underlying  cellular  tissues,  due  to 
the  special  germ — the  streptococcus  of  erysipelas.  It 
is  almost  unquestionably  settled  that  this  is  not  the 
ordinary  pyogenic  streptococcus.  Certainly  its  eflfects 
are  constant,  and  in  any  form  it  never  suppurates  unless 
mixed  with  other  septic  germs.  The  source  of  infection 
is  through  an  abrasion  or  wound,  and  though  some 
forms  are  looked  on  as  idiopathic,  this  is  probably  not 
ever  the  case.  Freely  contagious,  it  is  not  actively  so, 
and  contact,  usually  mediate,  is  necessary,  as  well  as  a 
break  in  the  tissues.  Erysipelas  is  an  especially  dan- 
gerous infection  to  puerperal  women. 

Symptoms  and  Forms. — Erysipelas  is  seen  in  three 
forms — the  facial,  the  general,  and  the  phlegmonous. 

By  general  erysipelas  is  meant  that  form  which  spreads 
from  one  part  of  the  body  until,  if  the  strength  be  not 
exhausted,  it  may  finally  involve  the  entire  cutaneous 
surface.  This  extent  of  spread  is  not  often  seen.  It 
may  rarely  occur  in  children.  The  character  of  the 
local  inflammation  is  about  the  same  as  in  the  facial 
form,  and  the  symptoms  are  similar,  except  in  the 
extent  of  surface  involved  and  the  protracted  attack. 

Phlegmonous  erysipelas  is  almost  invariably  ingrafted 
upon  a  wound,  commonly  in  an  extremity.  The  symp- 
toms of  phlegmonous  erysipelas  are  excessive  redness 
of  the  skin,  swelling  of  the  part,  a  burning  sense  of 
pain,  slight  pitting  on  pressure,  with  deep-seated  ach- 
ing pain,  tenderness,  and  evidence  of  suppuration  and 
septic  infection,  with  high  temperature. 

The  treatment  consists  in  early  free  incision  and 
drainage,  antiseptic  irrigation,  and  the  application  of 
a  hot  bichlorid  pack, — i  :  looo, — with  supportive  meas- 


ERYSIPELAS.  53 

ures.  The  various  preparations  of  iron  with  general 
treatment,  such  as  is  recommended  for  septicemia,  com- 
plete the  indications. 

Facial  Erysipelas — Symptoms. — The  beginning  is 
usually  a  spot  of  tenderness  upon  the  cheek  or  fore- 
head, reddened  and  slightly  swollen.  This  redness 
extends  usually  in  one  direction,  but  at  times  in  sev- 
eral. There  is  a  chill,  followed  by  high  temperature 
and  quick  pulse,  and  a  formation  of  small  blebs  on 
the  surface.  The  pain  or  burning  of  erysipelas  is  usu- 
ally slight.  The  temperature  is  often  105°  to  106°  F. , 
and  it  keeps  up  to  the  100°  mark  for  some  days,  with 
occasional  remittances  and  exacerbations.  At  times 
such  inflammation  stops  after  a  day's  spread  ;  at  others 
it  will  go  on  until  the  whole  face  has  been  involved. 
Usually  the  spread  is  slow  and  the  inflamed  part  be- 
comes pale,  with  slight  desquamation,  while  a  new  sur- 
face is  red  and  swollen.  This  spreading  is  alwa>s  by 
continuity  of  tissue ;  there  is  never  any  jumping  or 
migrating.  There  is  no  difference  from  the  symptoms 
in  the  general  form,  except  that  the  facial  variety  rarely 
leaves  that  part  of  the  body,  while  the  general  form  usu- 
ally starts  on  the  trunk.  The  germ  of  each  kind  is  the 
same,  and  when  such  spreading  forms  encounter  a 
wound,  cellulitis  with  phlegmon  is  likely  to  be  set  up. 

The  treatmetit  of  superficial  erysipelas  consists  in  the 
application  of  some  soothing  ointment — lanolin,  zinc 
ointment,  with  impregnations  of  ichthyol  are  favorites. 
My  own  experience  with  the  application  of  pure  car- 
bolic acid  to  the  margin  of  the  redness,  and  after  a 
minute  or  so  neutralizing  with  alcohol,  has  given  favor- 
able results.  Usually  after  one  or  two  paintings  its 
spread  will  be  arrested.  Five-grain  doses  of  the  sali- 
cylate of  soda  every  four  hours  appear  to  exert  a  favor- 
able influence.  As  the  cases  progress  and  during  con- 
valescence tonics  containing  iron  should  be  given,  and 
fairly  nourishing  diet  maintained. 

All  forms  of  erysipelas  are  contagious,  and  the  patients 


54 


ACTINOMYCOSIS. 


should  be  isolated,  and   every  care  be  taken   to   burn 
dressings  and  contaminated  bandages  and  drains. 

ACTINOMYCOSIS. 

In  recent  years  the  study  of  the  so-called  "lumpy 
jaw"  in  grazing  animals,  chiefly  cattle,  has  led  to  the 
description  of  an  infection,  called  actinomycosis,  due  to 
the  ray  fungus  found  in  grain. 

The   disorder   consists  of    the   presence  of  a   tumor, 


Fig.  8. — Actinomycosis  of  the  cheek  (Illich). 

which  is  usually  early  shown  to  contain  pus-like  fluid, 
with  granulation  tissue  somewhat  similar  to  that  of 
sarcoma.  The  fungi  of  actinomycosis  may  be  seen  in 
the  discharge  even  without  the  aid  of  a  microscope, 
and  appear  as  grayish  particles  about  the  size  of  a  mil- 
let seed,  sometimes  of  a  yellowish  or  greenish  color. 
In  the  early  growth  these  granules  are  soft,  but  later 
they  become  hardened  and  gritty. 

Whether  or  not  actinomycetes  are  actively  pyogenic, 
or  whether  the  infection  is  derived  from  the  germs  that 


ACTINOMYCOSIS. 


55 


gain  admission  from  without,  has  not  been  determined. 
The  disease  is  found  only  in  grazing  animals  and  in 
men,   and  the  genu  is  probably  admitted  with  food. 

The  fungus  usually  finds  its  way  into  tissue  through 
some  slight  wound,  inflicted  by  a  beard  or  grain.  Such 
deposits  are  usually  seen  about  the  face  or  neck, 
having  entered  by  way  of  the  mouth,  and  are  at  times 
found  in  the  female  breast  and  other  glands. 


Fig.  9. — Actinomycosis,  cervical  type  (Illich). 

The  diagnosis  from  sarcoma  and  tuberculosis  must 
be  made  by  the  history  and  the  finding  of  the  granules 
in  the  discharge.  The  microscope  will  always  settle 
the  matter  by  disclosing  the  fungus.  Besides,  it  does 
not  appear  that  secondary  deposits  are  found  in  the 
lymph-nodes  communicating  with  the  original  focus. 
There  is  little  pain  in  actinomycotic  deposits.  They 
grow  slowly  and  produce  a  very  gradual  impression  on 


56  ACTINOMYCOSIS. 

the  health,  except  when  secondary  deposits  in  the  lungs, 
liver,  or  other  viscera  have  taken  place,  which  is  of 
rare  occurrence. 

Treatment. — Free  extirpation  of  all  diseased  tissue 
is  the  first  step.  If  this  can  be  done,  the  chances  are 
against  recurrence.  In  the  face  and  jaw,  deposits  can 
often  be  removed  by  ver}^  free  excision.  At  times 
the  tongue  must  be  extirpated.  If  the  tumor  cannot 
be  removed,  in  the  course  of  years  death  follows  from 
exhaustion. 

The  administration  of  iodin  and  iodid  of  potassium 
with  construction  tonics  is  of  help  even  when  operation 
is  not  advisable. 

SUMMARY. 

Pyemia  is  the  direct  introduction  of  the  germs  of 
suppuration  into  the  open  blood-vessels,  sending  the  sup- 
purating matter  in  emboli  to  many  remote  organs,  in- 
ducing metastatic  abscess.  These  abscesses  are  attended 
with  daily  chills  and  exhausting  sweats.  A  clear  in- 
telligence is  usually  retained  until  the  last.  Jaundice, 
lung-infiltration,  and  pus  in  the  joints,  with  diarrhea, 
exhaustion,  and  death,  mark  the  course.  It  is  almost 
invariably  fatal. 

Erysipelas  is  an  infection  with  a  special  germ,  pro- 
ducing a  blood-poisoning ;  a  uniform  redness  over  the 
affected  parts,  usually  the  face  ;  high  temperature  and  a 
tendency  to  spread.  Constitutional  symptoms  are  severe, 
but  the  prognosis  is  usually  favorable.  Treatment  con- 
sists of  carbolic  acid  locally,  either  diluted  or,  if  in  full 
strength,  immediately  neutralized  by  alcohol.  The 
phlegmonous  form  requires  incision  and  drainage. 

Actinomycosis  is  an  infection  due  to  the  ray  fungus 
of  grain,  and  is  seen  in  the  face  and  neck.  It  is  usually 
painless.  It  is  differentiated  from  tuberculosis  by  the 
presence  of  the  fungus  in  the  growth,  visible  to  the 
naked  eye.  Treatment  is  unsatisfactory,  and  consists 
in  excision  when  possible. 


CHAPTER  VIII. 

SURGICAL  DIAGNOSIS.— PREPARATIONS  FOR 
OPERATION. 

SURGICAL  DIAGNOSIS. 

By  the  term  diagnosis  is  meant  the  study  of  the  symp- 
toms presented  by  any  lesion  and  the  determination 
of  the  classification  and  nomenclature.  By  differential 
diagnosis  is  meant  the  comparison  with  other  similar 
lesions,  and  a  conclusion  as  to  which  class  the  one  ob- 
served belongs. 

It  is  in  correct  appreciation  of  the  pathology  of  the 
conditions  presented  that  the  hope  of  a  successful  appli- 
cation of  remedies  for  that  condition  lies.  No  accurate 
conclusions  can  be  arrived  at  without  a  full  understand- 
ing of  all  the  causes  and  changes  which  belong  to  dis- 
ease, and  a  full  appreciation  of  all  the  influences  at  work 
in  the  economy.  Physiology,  anatomy, — both  in  health 
and  in  disease, — chemistry,  microscopy,  and  experimen- 
tation all  claim  full  recognition  in  this  study. 

Although  at  the  present  time  it  is  fair  to  say  that 
operative  surgery  has  nearly  reached  perfection  so  far 
as  human  endurance  goes,  yet  in  the  art  of  determining 
the  nature  of  the  condition  requiring  treatment  and  the 
probable  results  of  interference  there  is  a  wide  field  for 
inquiry.  The  steps  to  be  taken  in  the  discussion  of 
obscure  medical  lesions,  when  systematically  conducted, 
are  most  formal  and  laborious,  although  even  in  detail 
often  most  important.  The  dentist  has,  however,  little 
occasion  to  go  into  such  extended  investigation,  but 
some  part  of  the  system  is  essential  in  order  to  arrive 
at  intelligent  conclusions.  The  family  history,  which 
includes  a  knowledge  of  the  health  of  parents  if  living, 
or   their   age    at    death  ;    the    health   of  the  immediate 

57 


58  SURGICAL    DIAGNOSIS. 

family,  brothers,  and  sisters ;  and  if  trace  of  inherited 
disease  appears,  careful  investigation  should  go  on  into 
earlier  generations.  In  addition,  the  previous  history 
of  the  patient,  his  habits  regarding  smoking  and  drink- 
ing, the  character  of  his  employment,  the  date  of  the 
appearance  of  the  first  symptoms,  as  well  as  his  age, 
physical  vigor,  general  performance  of  functions,  and 
particularly  the  presence  of  abnormal,  or  variation  from 
the  normal,  ingredients  of  the  urine. 

In  surgical  conditions,  when  the  administration  of 
anesthetics  is  to  be  employed,  lesions  of  the  kidney  and 
of  the  heart  and  lungs  are  to  be  weighed  against  the 
urgency  of  the  operation.  The  existence  of  diabetes, 
albuminuria,  erysipelas,  and  hemorrhagic  diathesis  all 
interfere  with  the  safety  of  operations. 

In  the  study  of  surgical  lesions  we  look  first  to  the 
probable  cause,  or  etiology^  of  the  lesion,  to  be  found 
in  the  sex,  age,  race,  occupation,  previous  climatic 
surroundings,   as  well  as  inheritance. 

By  pathology  we  mean  the  changes  in  the  structures 
themselves  due  to  disease. 

By  stibjective  syinptonis  are  meant  headache,  pain,  and 
other  complaints  of  the  patient ;  while  the  condition  of 
the  pulse,  the  range  of  temperature,  and  the  presence 
of  swellings  are  objective  symptoms.  The  enlargement 
of  the  part,  displacement,  and  deformity,  etc.,  are  phy- 
sical signs. 

By  prognosis  is  meant  the  prediction  that  may  be 
made  as  to  the  outcome. 

The  study  of  these  various  manifestations  is  conducted 
first  by  obtaining  the  general  history,  the  symptoms 
and  signs,  then  carefully  inspecting  the  parts,  and 
patiently  comparing  the  injured  or  diseased  side  with 
the  sound  one,  the  damaged  function  with  the  normal 
one.  Valuable  information  is  obtained  by  this  com- 
parison, and  by  it  suspicion  of  disease  may  often  be 
excluded.  The  appearance  of  the  skin,  the  actual  and 
apparent  age,  the  signs  of  premature  decay,  the  exist- 


PREPARATIONS  FOR  OPERATION.  59 

ence  of  eruptions,  the  presence  of  cachexia,  or  consti- 
tutional blood  changes,  profound  anemia,  local  paral- 
ysis, irregular  pupils,  indications  of  dropsy,  swelling 
of  eyelids,  emaciation,  loss  of  hair,  wrinkled  counte- 
nance, scars,  tumors,  enlarged  glands — all  these  convey 
special  meaning  to  the  experienced  eye. 

The  measurement  of  the  parts^  especially  in  fracture 
and  in  swellings  over  the  liver,  heart,  and  limbs,  will 
disclose  variations  and  abnormal  conditions. 

By  palpation  and  manipulation  the  sense  of  touch 
often  gives  clear  information.  In  dislocations,  frac- 
tures, sprains,  abscesses,  broken  ribs,  and  injuries  of 
joints,  the  exploration  is  thus  made.  By  percussion 
in  surgery  the  existence  of  fluid  in  tumors  and  cavi- 
ties and  fluctuation  generally  are  determined.  The 
lungs,  the  pericardium,  the  abdomen,  all  yield  decisive 
and  explicit  information  in  response  to  skilful  palpation 
and  percussion. 

The  examination  of  the  tcrine  is  important  in  all  ob- 
scure conditions,  and  should  never  be  omitted  when  the 
administration  of  an  anesthetic  is  contemplated,  or  even 
when  an  operation  is  to  be  undertaken  without  it. 
While  it  is  true  that  it  may  sometimes  be  necessary  to 
operate  in  the  presence  of  the  contra-indications  arising 
from  disease  of  the  kidney,  it  is  to  be  remembered  that 
albumin  or  sugar  in  the  urine  should  discourage  explora- 
tive and  avoidable  surgery. 

PREPARATIONS   FOR   OPERATION. 

As  we  have  seen  that  the  course,  not  only  of  all  dis- 
ease, but  also  of  all  structural  change  in  disease,  arises 
through  the  agency  of  bacteria,  and  the  fact  that  such 
germs  are  constantly  alert  for  a  fertile  field  of  lessened 
resistance  to  colonize  and  multiply,  the  opportunity 
offered  by  a  fresh  wound  must  be  most  carefully  guarded 
by  the  surgeon.  The  ordinary  methods  of  cleanliness 
are  all  inadequate  for  this  occasion.  Those  intrusted 
with  these  preliminary  steps  should  be  impressed  with. 


60  PREPARATIONS    FOR    OPERATION. 

the  truth  that  if  the  field  be  rendered  thoroughly  asep- 
tic, and  all  instruments,  coverings,  dressings,  and  hands 
brought  in  contact  with  it  be  similarly  sterile,  any  organ 
or  structure  of  the  body  may  be  exposed  without  danger 
of  sepsis ;  but  that  failure  completely  to  effect  this  clean- 
liness is  almost  sure  to  be  followed  by  pus  and  destruc- 
tion of  function,  if  not  of  life. 

Besides,  it  is  to  be  remembered  that  these  germs  are 
present  everywhere,  and  must  not  only  be  faithfully 
removed  from  all  instruments  and  dressings,  but  must 
be  kept  from  subsequently  contaminating  them.  We 
have  also  seen  that  despite  such  cleanliness  or  asepsis 
some  germs  are  sure  to  gain  access  to  every  wound, 
and  only  the  vigor  of  the  patient,  through  the  repelling 
power  of  the  leukocytes,  prevents  their  colonization. 
Therefore  anything  th^t  lessens  the  productive  power 
of  the  germs  and  impoverishes  the  supply  of  nourish- 
ment upon  which  they  are  striving  to  subsist  dimin- 
ishes the  danger. 

By  sepsis,  or  rather  infection  in  this  sense,  is  meant 
the  partial  or  complete  colonization  of  the  germs  of  sup- 
puration. The  term  sepsis  in  surgery  is  usually  under- 
stood to  mean  constitutional  infection. 

By  antisepsis  is  meant  the  antagonism  of  infection 
which  has  already  taken  place.  The  agents  of  anti- 
sepsis are  chemical  germicides  in  the  living  tissues,  ster- 
ilization by  heat  on  inanimate  surfaces  the  habitat  of 
germs. 

By  asepsis  is  meant  the  prevention  of  infection  either 
by  cleanliness  or  germicides.  At  the  present  time  clean 
wounds,  as  uninfected  cuts  are  termed,  are  rarely  treated 
with  germicides  unless  contaminated  by  much  handling 
or  exposed  to  possible  infection  by  some  accidental 
touch  from  the  operation  field. 

Prior  to  any  operation  the  field  is  thoroughly  cleaned 
with  hot  water  and  soap,  and  in  many  instances  turpen- 
tine and  other  penetrating  irritants  are  used.  In  opera- 
tions about  the   mouth  and  the  eves  the  less  vigorous 


PREPARATIONS  FOR  OPERATION.  6l 

measures  are  employed,  but  when  the  field  can  be  easily 
reached,  a  poultice  of  soft  soap  diluted  with  linseed  oil 
is  often  applied  the  night  before,  and  the  washings  made 
at  the  hour  of  operation. 

After  the  preliminary  washing  the  skin  is  usually  cov- 
ered with  sterile  dressing  until  the  anesthetic  is  admin- 
istered, when,  after  a  final  cleaning,  the  wound  is  washed 
with  a  solution  of  mercury,  alcohol,  or  ether.  Wounds 
that  have  become  infected  should  be  cureted,  followed 
by  repeated  washings  with  hot  water  and  bichlorid  of 
mercury. 

As  a  matter  of  fact,  no  scrubbing  can  remove  all  the 
germs  from  an  infected  wound,  but  by  these  means  the 
conditions  may  be  made  so  favorable  that  primary  union 
may  be  obtained.  Irrigation  of  septic  wounds  or  unclean 
surfaces  during  operation  is  of  great  service  in  preventing 
suppuration. 

Solutions  for  irrigation  most  in  use  are  corrosive  sub- 
limate, I  :  looo  or  weaker,  or  normal  salt  solution, 
I  dram  to  a  pint  of  water.  The  latter,  though  not  a 
strong  antiseptic,  leaves  the  field  less  favorable  for  coloni- 
zation. 

For  the  cleansing  of  the  hands,  vigorous  washing  and 
scrubbing  with  hot  water  and  soap,  and  later  dipping 
them  in  weak  bichlorid  solution,  is  the  common  plan. 
Great  care  must  be  taken  to  clean  the  finger-nails.  Many 
surgeons  use  rubber  gloves  made  for  the  purpose  ;  these 
can  be  sterilized  by  boiling, 

Tablets  of  corrosive  sublimate — 7^  grains — are  obtain- 
able at  the  pharmacists,  and  one  of  these,  if  placed  in  a 
pint  of  water,  will  make  a  solution  of  i  :  1000. 

A  solution  of  formalin — -^  of  i  per  cent. — makes  a 
satisfactory  irrigant.  iVbout  15  drops  of  the  official  solu- 
tion in  a  pint  of  water  give  about  the  strength.  A 
stronger  solution  may  be  used  to  mop  sinuses  or  ulcers 
about. the  field  to  be  disinfected. 

Carbolic  acid  solutions  of  full  strength  may  be  applied 
to  suppurating  tracts,  and  in  a  few  minutes   time  may 


62  PREPARATIONS  FOR  OPERATION. 

be  neutralized  by  pouring  absolute  alcohol  over  the  cau- 
terized surface.  A  solution  of  carbolic  acid  in  water — 
I  :  30 — may  be  used  for  irrigation.  During  the  opera- 
tion it  also  serves  to  submerge  catheters  and  sounds,  as 
well  as  other  instruments. 

Lysol  makes  an  odorless  solution  for  sterilizing 
instruments,  and  is  sufficiently  strong  for  most  purposes. 

Dental  instruments  that  are  being  used  upon  a  septic 
case  may  be  rapidly  sterilized  by  dipping  them  in  wood- 
alcohol  and  passing  then  through  a  flame.  The  alcohol 
will  rapidly  burn  off  without  damage  to  the  instrument. 

Iodoform  has  so  offensive  an  odor  that  it  is  now  little 
used.  After  careful  preparation  all  dressings  are  steril- 
ized by  dry  heat  in  ovens    lade  for  the  purpose. 


CHAPTER    IX. 
ANESTHESIA. 

This  term  is  understood  to  imply  the  loss  of  sensi- 
bility to  pain,  and  is  applied  to  both  general  insensibility 
and  local  numbness.  Local  anesthesia  is  induced  both 
by  the  application  of  some  benumbing  mixture  and  by 
the  infiltration  of  the  surrounding  skin  with  one  of  the 
well-known  anesthetizing  agents.  The  freezing  mixtures 
are  all  objectionable,  because,  while  never  acting  per- 
fectly, they  often  leave  intense  smarting  and  burning  pain 
in  the  cut  after  the  numbness  has  subsided.  Besides, 
they  lessen  the  vitality  of  the  part  and  tend  to  prevent 
union.  Ice  and  salt  applied  on  the  spot  in  a  small  piece  of 
gauze  and  ether  poured  over  the  skin  are  both  emergency 
measures  that  serve  to  divert  the  apprehensions  of  the 
patient.  The  spray  of  ethyl-chlorid  which  is  usually 
used  for  local  superficial  anesthesia  is  prepared  in  a  glass 
tube.  When  the  small  cap  is  removed,  the  spray  is 
thrown  over  the  field  until  a  white  frost  appears.  As 
previously  stated,  these  measures  are  unsatisfactory, 
although  they  often  serve  a  valuable  purpose. 

The  injection  and  infiltration  method,  however,  has 
been  a  wonderful  boon  to  the  sufferer,  and  recent  perfec- 
tions of  the  method  have  made  it  possible  to  perform 
operations  of  considerable,  even  capital,  magnitude  with- 
out pain.  Practically  speaking,  all  surgeons  agree  that 
local  anesthesia  should  not  be  employed  for  extensive 
operations  unless  the  general  anesthetic  is  physiologically 
contraindicated. 

The  materials  commonly  used  are  cocain  and  eucain 
hydrochlorate.  Locally,  especially  to  mucous  mem- 
branes,  a  5  per  cent,   solution   applied  externally  will 

63 


64  ANESTHESIA. 

produce  a  numbness  sufficient  for  superficial  cuts.  In 
the  hypodermic  use  of  cocain  it  is  best  to  employ  a 
weak  solution,  about  i  or  2  per  cent,  and  infiltrate' 
adjacent  structures.  From  f  to  i^  drams  of  a  solution 
containing  ^^  to  |-  grain  of  cocain  may  be  injected  under 
the  skin,  and  a  considerable  extent  of  insensibility  will 
be  obtained  in  four  minutes,  its  effect  continuing  for 
twenty  minutes.  If  this  is  done  in  a  region  where  the 
circulation  can  be  cut  off  with  a  ligature,  the  consti- 
tutional effect  is  prevented.  This  method  is  used  in 
extracting  teeth  and  roots,  removal  of  tissues  from  any 
exposed  surface,  amputation  of  the  fingers,  circumci- 
sion, and  even  the  performance  of  herniotomy.  The 
author  almost  invariably  uses  this  agent  in  performing 
circumcision  on  the  youth  and  adult. 

Cocain,  employed  hypodermically,  is  unsafe  for  chil- 
dren under  ten  years  of  age.  The  symptoms  of  cocain 
poisoning  are  nausea,  dizziness,  pallor,  cold  clammy 
skin,  severe  headache,  with  faintness  and  dilated 
pupils.  If  the  more  severe  symptoms  appear,  the  pa- 
tient becomes  delirious,  the  pulse  slow,  and  at  last  con- 
vulsions and  heart  failure  intervene.  In  the  adult  a 
grain  or  more  is  required  to  produce  severe  symptoms, 
though  in  some  instances  even  ^  grain  will  cause  dis- 
comfort. There  is  no  physiologic  antidote,  but  stimu- 
lants,—whisky,  ammonia,  hypodermics  of  strychnin,— 
warmth,  and  rest  are  the  indications. 

Eucain  is  less  dangerous,  and  is  by  many  preferred. 
The  dose  and  method  are  about  the  same.  It  is  less 
reliable  as  a  local  anesthetic,  and  externally  has  but 
slight  numbing  effect. 

Chloretone  in  ^-grain  infiltration  solution,  injecting 
I  or  2  drams,  while  a  less  reliable  agent,  is  a  very 
efficient  one,  and  without  danger. 

Schleich's  solution  of  morphin  and  cocain  is  used  for 
infiltration  of  larger  surfaces,  but  has  no  especial  value. 
If  care  is  observed  in  the  cocain  or  eucain  solution, 
using  no  more  than  ^  grain  to  i  dram  or  i|-  drams  of 


SPINAL    ANESTHESIA    BY    COCAIN.  65 

water,  every  ordinary  emergency  requiring  local  anes- 
thesia can  be  safely  met,  and  more  satisfactorily  than 
by  other  supposedly  less  dangerous  mixtures. 

Spinal  Anesthesia  by  Cocain. — The  injection  of 
either  of  the  aforenamed  agents  into  the  spinal  canal 
by  a  specially  made  syringe,  between  the  first  and 
the  second  lumbar  vertebrae,  produces  anesthesia  of 
all  the  body  below  the  intestines,  and  permits  of  any 
capital  operation  below  this  point  without  pain.  For 
the  past  two  years  this  agent  has  been  generally  em- 
ployed for  this  purpose.  The  question  is  still  in  dis- 
pute as  to  whether  this  method  is  safer  than  general 
anesthesia,  but  it  is  pretty  well  conceded  that,  save  in 
conditions  contraindicating  the  general  method,  spinal 
cocainization  is  not  to  be  preferred.  The  method  has 
not  been  sufficiently  tried  to  determine  its  mortality- 
rate,  but  it  is  not  always  efficacious  in  destroying  sen- 
sibility ;  the  after-effects  are  even  more  distressing 
than  those  of  ether  or  chloroform,  and  the  care  and 
skill  required  in  its  use  are  not  less  than  in  general 
anesthesia.  The  danger  of  producing  septic  menin- 
gitis is  not  to  be  forgotten.  That  it  has  a  fixed  place 
in  general  surgery  is,  however,  unquestioned. 

General  Anesthesia. — The  administration  of  gen- 
eral anesthetics  dates  back  only  to  1842,  but  is  recog- 
nized as  the  greatest  boon  to  humanity  in  connection 
with  surgery,  dentistry,  and  obstetrics  since  medicine 
became  a  profession. 

All  the  agents  for  producing  general  anesthesia  act 
in  the  same  way:  by  temporarily  overcoming  the  power 
of  the  control  of  the  spinal  nerve-centers.  Chloroform 
and  ether  are  largely  the  preponderating  agents  in  gen- 
eral surgery;  nitrous  oxid,  in  dentistry.  Certain  con- 
ditions of  the  patient  make  one  or  another  agent 
unsafe. 

Ether  cannot  well  be  used  in  the  presence  of  burning 
gas  or  lighted  lamp  without  the  danger  of  explosion. 
Disease  of  the  kidnevs  and  bronchitis  constitute  contra- 


66  ANESTHESIA. 

indications  to  ether;  patients  suffering  with  asthma, 
atheroma  of  the  arteries,  or  hypertrophy  of  the  heart 
should  also  be  subjected,  by  preference,  to  chloroform. 
Before  definitely  determining  the  propriety  of  any  opera- 
tion, the  chest  should  be  carefully  examined  and  the 
urine  tested  for  disease  of  the  kidneys.  In  disease  of 
the  heart,  except  hypertrophy,  ether  is  preferable.  In 
disease  of  the  kidney  and  lungs,  chloroform  answers 
best. 

The  bowels  should  be  emptied  before  any  operation. 
No.  solid  food  should  be  given  for  twelve  hours  before 
the  administration  of  the  anesthetic.  All  constriction 
should  be  removed;  the  mouth  examined  for  false  teeth, 
gum,  tobacco,  etc.  A  hypodermic  syringe  charged  with 
strychnin  should  be  at  hand,  and  whisky  and  ammonia 
should  be  ready  if  needed.  The  patient  to  be  etherized 
should  lie  on  his  back,  though  the  semierect  position, 
if  need  be,  can  be  more  safely  taken  than  when  chloro- 
form is  employed.  Special  inhalers  are  manufactured 
for  giving  ether.  Usually  eight  to  fifteen  minutes  are 
required  to  complete  insensibility.  The  respirations 
must  be  carefully  watched.  As  noted  before,  sud- 
den dilatation  of  the  pupils  or  dusky  color  in  the  face 
indicates  great  danger,  and  demands  immediate  with- 
drawal of  the  ether,  the  injection  of  strychnin,  and 
perhaps  the  institution  of  artificial  respiration.  The 
patient  taking  ether  breathes  much  more  deeply  and 
stertorously  than  one  taking  chloroform;  usually  the 
patient  is  talkative,  or  perhaps  violent  in  the  early 
stages.  When  the  reflex  of  the  eyelid  is  gone,  ascer- 
tained by  touching  the  conjunctiva  with  the  finger,  the 
patient  is  ready  for  the  operation.  Usually  from  four 
to  eight  ounces  are  required  to  keep  the  patient  in  the 
anesthetized  state  for  one-half  hour. 

Chloroform  is  quite  irritating  to  the  nose  and  lips  of 
the  patient,  and  these  should  be  protected  with  vaselin 
while  the  inhalation  is  going  on.  The  inhaler,  which 
is  either  a  handkerchief  or  a  paper  cone,  or  preferably 


GENERAL    ANESTHESIA.  67 

the  wire-covered  receiver  of  Esmarch,  should  not  touch 
the  skin.  The  patient  in  the  early  stages  should  be 
allowed  a  breath  of  pure  air  from  time  to  time.  The 
pupils  should  be  watched  carefully  for  sudden  dilatation, 


Fig.  10. — First  movement :  inspiration  (Murray). 

and  the  finger  kept  over  the  pulse.  Loud,  stertorous 
breathing,  pallor  of  the  face,  feeble  or  absent  pulse  in- 
dicate danger.      If  there  is  danger  of  asph3^xiation,  the 


II. — Second  movement:   expiration  (Murray). 


tongue  should  be  pulled  forward,  and  the  glottis  opened 
by  pushing  forward  on  the  angles  of  the  lower  jaw.  If 
respiration  ceases,  resort  must  be  made  to  artificial 
methods,   described   under  the  head  of  Drowning.     If 


68  ANESTHESIA. 

the  heart  becomes  feeble,  strychnin  is  to  be  injected. 
Syncope  may  occur  early  in  the  administration  and 
indicates  heart  failure.  The  head  is  to  be  lowered, 
artificial  respiration,  with  strychnin  and  the  galvanic 
battery,  if  available,  kept  up  faithfully  even  after  there 
appears  to  be  no  hope.  Usually  about  two  drams  to 
half  an  ounce  of  chloroform  are  required  for  a  half-hour 
operation.  Chloroform  and  ether  require  an  expert  for 
safe  administration,  and  under  no  circumstances  should 
general  anesthesia  be  induced  without  the  presence  of 
a  reliable  third  party. 

Nitrous  oxid  is  the  anesthetic  usually  selected  by  the 
dentist  in  the  extraction  of  teeth,  and  is  used  by  the  sur- 
geon for  very  short  operative  steps.  The  anesthesia 
cannot  be  kept  up  longer  than  about  one  minute.  Ni- 
trous oxid  produces  insensibility  by  diminishing  respi- 
ration, which,  however,  does  not  wholly  cease,  and 
should  be  carefully  watched.  The  gas  is  preserved  in 
a  metallic  cylinder,  and  to  this  a  rubber  bag  is  attached, 
having  a  mouth-piece  with  a  valve.  The  patient  may 
be  either  erect  or  recumbent.  The  flow  of  gas  is  regu- 
lated  by  a  stop-cock  on  the  cylinder.  The  mouth  is 
kept  open  by  a  gag,  as  it  would  be  held  firmly  shut  by 
the  muscular  rigidity,  the  muscles  not  relaxing  as  in 
chloroform  anesthesia.  When  the  mouth-piece  is  in- 
serted the  nostrils  are  compressed  by  thumb  and  finger, 
and  the  patient  inhales  through  the  mouth.  Soon 
slight  cyanosis  appears  on  the  cheeks  and  ears,  and  in 
a  minute,  or  sometimes  less,  the  breathing  becomes  slow 
and  stertorous ;  the  pupils  are  dilated,  and  the  conjunc- 
tivae insensible.  The  pulse  and  respiration  should  be 
carefully  watched.  There  is  really  almost  no  danger, 
although  the  appearance  of  the  patient  is  alarming,  but 
in  event  of  failure  of  either  heart  action  or  respiration 
the  usual  methods  should  be  employed.  Consciousness 
usually  returns  within  a  minute  or  so  after  the  inhala- 
tion stops.  Its  return  is  often  announced  by  a  cry,  fol- 
lowed by  laughter  of  a  mild,  hysteric  form. 


SUMMARY.  69 

Schleich  mixture  is  a  compound  of  chloroform  45 
parts  by  volume,  petroleum  15  parts,  and  ether,  from 
80  to  180.  It  must  have  a  boiling-point  between  99° 
and  104°  F.  It  is  claimed  that  this  mixture  when 
inhaled  is  more  readily  taken,  and  that  consciousness 
returns  more  promptly  after  the  operation,  with  less 
succeeding  distress,  and  that  it  is  less  dangerous  than 
either  chloroform  or  ether  alone.  It  has  never  become 
popular  in  this  country. 

Practically  ether  is  a  safer  anesthetic  than  chloro- 
form, and  in  but  moderately  experienced  hands  gives 
less  mortality.  Its  occasional  disastrous  after-effects 
upon  the  kidneys  and  lungs  in  a  measure  make  up 
for  this  apparent  advantage.  The  vomiting  and  pro- 
tracted nausea,  together  with  the  ether  odor  after  in- 
halation, sometirnes  do  great  damage  to  sensitive  wounds 
after  capital  surgical  operations. 

Statistics  indicate  chloroform  to  have  a  mortality  of 
about  50  per  cent,  greater  than  ether;  but  in  skilled 
hands  there  is  much  less  difference.  The  mortality 
from  chloroform  is  about  i  to  3000  inhalations. 

Chloroform  is  used  by  preference  in  most  southern 
and  western  hospitals  of  this  country.  In  rural  practice 
it  is  almost  exclusively  used  because  of  its  smaller  bulk 
and  greater  convenience. 

SUMMARY. 

Siirgical  diagnosis  means  the  determining  from  what 
malady  the  patient  suffers.  Age,  sex,  family,  and  per- 
sonal history,  habits,  occupation,  are  all  important. 

Symptoms  :  Condition  of  liver,  kidneys,  lungs,  and 
heart ;  appearance  of  the  skin,  measurements,  palpation,, 
manipulation,  the  use  of  aspirator,  the  temperature  of 
the  body,  are  all  included  in  the  steps. 

In  preparing  for  an  operation  not  only  must  the  diag- 
nosis be  made,  if  possible,  but  whether  an  anesthetic  is 
used  or  not,  all  points  of  contraindication,  as  diseases  of 
kidneys,  heart,   lungs,  or  blood,  etc.,   are  to  be  consid- 


70  ANESTHESIA. 

ered.  The  field  must  be  rendered  aseptic,  or  in  accidents, 
vigorous  antiseptic  cleansing  employed,  and  careful 
attention  to  dressings  and  after-treatment  provided  for. 

The  anesthetic  may  be  local,  usually  cocain  or  eucain, 
in  diluted  solutions  of  |-  to  ^  grain  ;  or  general,  as  chloro- 
form, ether,  or  nitrous  oxid.  The  contraindications  to 
the  use  of  chloroform  are  feeble  heart,  lung  diseases, 
and  kidney  lesions.  In  emergency  operations  ether 
is  unsuitable  at  night  ;  it  is  likewise  in  the  presence  of 
kidney  lesions  and  in  bronchitis  objectionable.  Pneu- 
monia may  be  induced  by. prolonged  inhalation  of  ether. 
Artificial  respiration,  injections  of  strychnin  and  nitro- 
glycerin, may  be  employed  if  dangerous  symptoms  arise. 
The  pulse  and  respiration  and  the  pupils  must  always  be 
carefullv  watched  bv  the  anesthetizer. 


CHAPTER   X. 
WOUNDS,  INCLUDING    SHOCK. 

The  essential  dangers  of  all  wounds,  whether  opera- 
tive or  accidental,  are  hemorrhage,  shock,  and  sepsis. 
Were  it  not  for  the  terrors  of  hemorrhage,  many  who 
are  deterred  by  fear  would  essay  the  role  of  surgeon. 
We  have,  however,  already  seen  that  a  cool  judgment 
will  be  able  to  control  almost  all  external  hemorrhages. 
It  is  only  when  by  accident,  in  dissecting  tumors  and 
adhesions,  a  large  vessel  in  the  neck,  axilla,  or  groin 
is  torn  open,  or  a  chance  cut  divides  a  very  large  artery, 
that  sudden  exsanguination  to  a  fatal,  or  even  very 
alarming,  degree  can  occur  in  the  hands  of  a  surgeon 
of  ordinary  skill.  The  pathologic  conditions  may  cause 
a  persistent  loss  of  blood  ending  disastrously,  but  ordi- 
narily very  severe  external  hemorrhage  is  easily  man- 
aged. This  subject  is  elsewhere  discussed,  as  well  as 
the  special  phase  of  hemorrhagic  diathesis. 

Shock  is  the  impression  made  on  the  nervous  system 
by  the  traumatism  of  severe  injuries  and  operations. 
Though  a  somewhat  similar  depression  may  follow 
extreme  fright  without  other  injury,  there  is  no  doubt 
that  a  very  powerful  factor  in  shock  is  loss  of  blood. 
The  pathology  of  the  condition  is  not  understood,  and, 
independent  of  hemorrhage  and  anesthesia,  it  is  not 
often  that  any  distinct  lesion  can  be  made  out  post- 
mortem. Age,  temperament,  surroundings,  all  influ- 
ence severity  of  shock.  The  young  and  confident  and 
cheerful  bear  severe  injuries  proportionably  better  than 
the  old  or  gloomy.  The  situation  of  the  injury  also  in- 
fluences the  severity  of  the  depression. 

Symptoms. — Great  depression,  cold  skin,  sunken  eyes, 

71 


J2  WOUNDS,    INCLUDING    SHOCK. 

temperature  96°  to  98°  F.,  respiration  shallow,  pulse 
feeble  and  quick,  nausea,  faintness,  and  often  indiffer- 
ence to  all  surroundings.  These  symptoms  appear  im- 
mediately upon  receipt  of  the  injury,  or  on  recovery 
from  the  anesthetic,  while  the  depression  from  concealed 
hemorrhao:e,  from  which  it  must  be  differentiated, 
comes  on  two  or  three  hours  later.  In  the  hemor- 
rhage, too,  the  patient  is  restless,  anxious,  has  extreme 
thirst,  and  suffers  from  dyspnea.  None  of  these  symp- 
toms is  so  pronounced  in  shock,  and  except  the  thirst, 
they  are  usually  not  marked  at  all. 

Prognosis  of  shock  is  controlled  by  the  conditions 
named.  It  may  promptly  disappear,  even  though  at 
first  quite  profound.  Pain  and  hemorrhage  add  to 
the  intensity,  and  when  these  are  corrected,  relief  is 
often  very  prompt.  Usually,  when  not  progressive 
after  the  first  hour  or  so,  the  prognosis  is  good.  When, 
however,  improvement  is  not  marked  in  six  or  eight 
hours,  the  chances  become  greatly  lessened,  though 
reaction  is  often  witnessed  even  after  twelve  or  more 
hours  of  profound  shock.  When  improvement  begins, 
the  pulse  increases  in  volume  and  diminishes  in  fre- 
quency, and  the  body  warmth  returns,  the  tempera- 
ture oroinof  above  the  normal.     This  is  termed  reaction. 

Treatment. — Precaution  should  be  taken  before  any 
operation  to  secure  warmth  and  protection.  Stimulants 
are  to  be  given  to  the  weak,  and  such  other  medicines 
as  are  indicated  to  preserve  as  nearly  as  possible  a 
healthful  condition  of  the  system.  Everything  is  done 
to  control  hemorrhage.  When  this  has  been  excessive, 
the  saline  solution  elsewhere  described  is  to  be  employed, 
and  indeed  even  when  there  is  no  history  of  bleeding,  it 
has  seemed  of  great  value.  Warmth  is  applied  to  the 
body  by  hot-water  bottles  and  gentle  frictions.  The 
head  should  be  lowered,  hypodermic  injections  of 
whisky,  strychnin,  nitroglycerin,  morphin  (if  there  be 
pain),  as  indicated.  Perfect  quiet  should  be  main- 
tained  and    comforting    assurances   given    the   patient. 


WOUNDS.  73 

Injections  of  hot  salt  water  into  the  rectum  are  less 
efficient  than  the  direct  introduction  of  the  saline 
solution,  but  in  the  absence  of  suitable  apparatus  may 
be  employed. 

Sepsis. — Infections  have  already  been  so  far  consid- 
ered that  it  is  but  left  to  say  that  all  surfaces  upon  the 
skin  or  accessible  mucous  membrane  should  be  thor- 
oughly prepared  before  operation,  and  all  wounds  care- 
fully cleaned  with  soap  and  hot  water,  and  then  further 
sterilized  by  germicides  and  antiseptics. 

WOUNDS. 

We  define  a  wound  as  a  solution  of  the  continuity  of 
the  soft  parts,  made  by  cutting  or  tearing.  Simple 
wounds  are  those  that  have  a  tendency  to  repair,  pass- 
ing successively  through  the  ordinary  course.  Infected 
wounds  are  those  in  which  germs  have  effected  coloniza- 
tion. Here  we  have  a  disposition  to  extend  and  to  show 
gangrenous  or  inflammatory  tendencies,  with  general 
systemic  symptoms. 

Wounds  are  incised^  punctured^  lacerated^  contused^ 
giinshot^   and  poisoned. 

Contused  and  lacerated  wounds  show  much  the 
same  conditions.  The  surrounding  tissues  are  bruised 
and  discolored,  and  if  lacerated  there  is  a  tearing  of  the 
external  and  often  the  deeper  parts,  to  every  differing 
degree.  In  parts  of  contused  wounds  the  tissues  may 
be  almost  pulpified.  Usually  there  is  little  hemorrhage 
in  either  contused  or  lacerated  woimds,  though  there 
may  be  considerable  extravasated  blood.  The  pain  is 
usually  more  persistent  than  in  incised  wounds,  and 
the  aching  continues. 

Treatment. — In  contusions  without  break  of  the  skin 
cold  applications,  often  the  cold  drip,  offer  the  best 
plan  of  treatment.  Witch  hazel;  solutions  of  dilute 
lead-water,  with  one-fourth  part  laiidanum,  and  other 
evaporating  lotions  are  appropriate  in  less  severe 
bruises.      Later,   hot    applications   promote   absorption 


74  WOUNDS,    INCLUDING    SHOCK. 

of  the  effused  blood.  When  lacerations  are  present, 
thorough  cleaning  should  be  made  with  hot  water  and 
soap,  and  later  measures  for  antisepsis  or  asepsis  and 
to  control  hemorrhage  employed.  Devitalized  tissue, 
sloughs  of  skin  or  muscle  should  be  promptly  removed. 
The  edges  of  the  wound  should  be  approximated  as 
nearly  as  can  be  done  and  insure  drainage.  Deep 
wound  cavities  should  be  packed  with  gauze. 

The  incised  wound,  whether  operative  or  accidental, 
presents  the  most  favorable  opportunity  for  repair;  often 
if  properly  managed  it  will  heal  without  perceptible 
scar.  It  is  the  result  of  a  cut  by  a  sharp  instrument, 
is  usually  of  moderate  depth,  and  the  edges  are  so  placed 
as  to  be  easily  brought  into  accurate  adjustment. 

The  first  step  of  treatment  is  control  of  hemorrhage, 
either  by  pressure  or  ligature.  In  small  wounds  pres- 
sure and  torsion  usually  suffice,  though  spurting  vessels 
should  either  be  tied  or  compressed  by  sutures.  The 
wound  itself  should  be  thoroughly  cleansed,  and  if 
accidental,  rendered  aseptic  by  germicides ;  operative 
wounds,  if  proper  preparation  has  been  made,  do  not 
need  this.  Hot  sponges  applied  to  oozing  surfaces  will 
often  control  annoying  bleeding.  As  a  rule  it  is  better 
to  secure  absolute  hemostasis  before  closing  a  wound 
in  which  primary  union  is  desired.  In  all  large  wounds 
this  is  imperative,  but  in  small  and  shallow  wounds  the 
siitures  will  often  arrest  bleeding  that  cannot  be  com- 
pletely checked  by  sponging  and  pressure. 

Sutures  of  silkworm-gut,  catgut,  or  silk  should  be  so 
introduced  as  to  close  the  deeper  part  of  the  cut  as  well 
as  the  superficial,  lest  there  accumulate  in  the  dead 
space  effused  fluids  to  favor  infection.  Drainage  is  to 
be  employed  when  such  effusion  is  feared.  The  drain, 
which  may  be  either  gauze  or,  in  larger  wounds,  rubber 
tubing,  should  be  removed  in  from  twelve  to  thirty-six 
hours,  as  by  this  time  all  uninfected  wounds  have 
sufficiently  ceased  to  receive  the  extravasated  fluids  as 
to  be  safe. 


TREATMENT    OF    PUNCTURED    WOUNDS.  75 

In  infected  wounds  i^ro vision  must  be  made  to 
permit  the  escape  of  inflammatory  products.  Here 
drainage  is  necessary  to  prevent  extravasation.  Often 
in  uninfected  wounds  a  suture  left  untied  at  the  first 
dressing  can  be  tied  when  the  drain  is  removed.  In  the 
tying  of  sutures  tension  should  be  avoided.  After  suture 
a  sterile  dressing  is  placed  well  over  the  wound.  If  closed 
without  drainage,  the  uninfected  wound  may  be  left  for 
from  three  to  six  days  without  inspection,  unless  it 
becomes  painful  or  the  temperature  rises.  If,  on  inspec- 
tion, evidences  of  infection  are  present,  such  of  the 
sutures  as  seem  indicated  are  removed  and  irrigation 
with  drainage  employed.  When  all  goes  well,  sutures 
may  be  allowed  to  remain  for  from  six  to  eight  days  if 
necessary.  In  wounds  of  the  face  it  is  usually  best  to 
remove  sutures  by  the  fourth  day. 

Punctured  wounds  are  made  by  pointed  instruments 
or  foreign  bodies,  sometimes  sharp,  sometimes  quite 
blunt.  Not  rarely  splinters,  broken  needles,  thorns, 
fish-hooks,  and  other  foreign  bodies  remain  in  the 
wound.  Unless  such  vulnerating  bodies  invade  a  laro;e 
blood-vessel,  a  clean  punctured  wound  made  by  a  sharp 
object  causes  little  damage.  When  septic,  or  when 
blunt  or  lacerating,  as  accidental  wounds,  usually  the 
defective  drainage  encourages  inflammation,  which  often 
becomes  a  very  serious  matter.  Should  a  foreign  body 
be  retained,  it  should  be  removed  if  located.  Splinters 
and  thorns  can  often  be  seen,  and  broken  needles  and 
pieces  of  glass  can  be  felt.  The  X-ray  will  sometimes 
be  of  help.  Even  when  the  foreign  body  is  known  to 
be  in  the  structures  but  cannot  be  located,  it  is  not 
wise  to  search  blindly  for  it. 

Treatment. — When  such  wounds  seem  favorable  for 
healing  and  free  from  foreign  bodies  or  marked  infection 
they  should  be  closed,  either  by  sealing  with  gauze  and 
collodion  or  dressing  with  a  gauze  pad.  If  pain  and 
tenderness  continue,  the  wound  should  be  freely  enlarged 
under  cocain  anesthesia,   to  facilitate  drainage.     A  hot 


76  WOUNDS,    INCLUDING    SHOCK. 

bichlorid  pack  should  be  used  as  a  poultice  until  the 
soreness  passes  away,  when  the  lesion  should  be  treated 
as  a  lacerated  wound. 

If  it  is  suspected  that  foreign  bodies  are  imbedded  in 
the  wound,  but  it  is  impossible  to  locate  them,  incision 
and  drainage  should  be  kept  up  until  the  body  is  located 
or  the  wound  begins  to  heal.  Such  wounds  usually 
bleed  very  little.  Of  course,  if  arteries  or  veins  of  any 
size  are  penetrated,  the  wound  should  be  enlarged  and 
the  bleeding  point  secured. 

Poisoned  wounds  are  practically  only  those  inflicted 
by  the  sting  or  fang  of  some  venomous  reptile  or  insect. 
The  bites  of  animals  not  suffering  from  disease  are  no 
more  harmful  than  other  punctured  wounds,  unless  by 
accident  some  poison  from  offal  or  carrion  be  thus  in- 
troduced. Few  insects  in  this  country  occasion  any 
serious  injury  other  than  painful  stings,  and  perhaps 
none  causes  fatal  issue.  Spiders,  scorpions,  and  centi- 
pedes cannot  destroy  life,  except  very  rarely  in  the 
feeble  or  in  children.  Among  serpents,  rattlesnakes, 
copperheads,  and  the  spreading  adder  are,  however, 
venomous  enough  fatally  to  infect  any  one,  and  death 
often  follows  quickly. 

The  symptoms  of  such  infections  are  burning  pain, 
swelling,  shock,  nausea,  and  vomiting,  and  in  the  severe 
forms  feeble  pulse  and  mental  wandering.  Of  course, 
the  history  is  necessary  in  order  to  make  an  accurate 
diagnosis. 

Treatment.— That  of  stings  of  bees  and  other  insects, 
including  that  of  the  tarantula  and  scorpion,  should 
consist  in  applications  of  dilute  ammonia  or  saturated 
solution  of  soda  bicarbonate.  If  need  be,  stimulants 
may  be  employed. 

Serpent-bites,  as  previously  referred  to,  require  very 
energetic  measures.  If  upon  an  extremity,  a  ligature 
should  be  tightly  applied  above  the  bite,  and  the  point 
freely  excised  and  cauterized  with  nitric  acid,  or,  pref- 
erably,  the   "actual  cautery."     If  the  wound  be  well 


SUMMARY.  yy 

sucked  or  a  cupping-glass  applied  before  cauterization, 
soon  after  reception,  it  is  a  great  help,  and  harmless  to 
any  one  applying  an  unbroken  lip  to  the  bite.  A  solu- 
tion of  permanganate  of  potassium  lo  per  cent.,  injected 
into  the  wound,  is  highly  commended.  Usually  free 
stimulation  with  whisky  is  to  be  employed.  If  such 
patients  do  not  perish  in  from  eight  to  twelve  hours,  the 
prognosis  becomes  more  favorable. 

.Dissection  wounds  have  been  referred  to  in  another 
place  in  discussing  Septicemia.  Hydrophobia  is  also 
separately  described. 

Gunshot  wounds  require  no  other  notice  here  than 

the  peremptory  caution  never  to  probe  them  until  they 

have  been  thoroughly  cleaned,  and  not  then  unless  some 

clear  indication   is  present.      They  should   be   cleaned, 

closed  up,  and  treated  as  a  punctured   wound.     When 

involving  serious  relations,  the  general  surgeon  should 

be  summoned. 

SUMMARY. 

Shock  after  wounds  is  due  largely  to  hemorrhage. 
Temperament  and  age  also  influence  it.  If  the  bleed- 
ing stops  with  warmth  and  support,  the  patient  usuallv 
reacts  in  from  two  to  six  hours.  The  treatment  is 
warmth  and  quiet,  with  control  of  the  hemorrhage  and 
pain.     Stimulants  should  be  given  as  needed. 

Wounds  are  breaks  in  the  soft  parts  due  to  violence. 
They  are  incised,  punctured,  and  contused.  Incised 
wounds  should  be  cleaned,  the  hemorrhage  controlled, 
the  wound  sewed  up,  dressed  antiseptically,  and  drained 
if  required.  Punctured  wounds  should  be  enlarged  if 
drainage  indicates  it,  and  kept  well  open  with  hot  ap- 
plications and  antiseptic  poultices.  Contused  wounds 
require  cleaning  and  drainage,  with  dressings  to  aid 
granulation. 

Foreign  bodies  in  wounds  should  be  removed  when 
located,  but  blind  searching  is  harmful. 

Insect-  and  serpent-bites  should  be  constricted  if  pos- 
sible, excised,  and  cauterized  when  dangerous. 


CHAPTER   XI. 
EMERGENCIES. 

HYDROPHOBIA. 

Hydrophobia,  or  rabies,  in  man  is  never  primary, 
but  is  produced  by  an  infection  from  some  animal 
affected  by  the  disease.  This  infection  is  almost  always 
by  the  saliva,  although  other  fluids  of  the  animal  have 
full  power  of  transmission.  Besides  the  dog,  cats, 
wolves,  and  foxes  may  develop  the  disease  sponta- 
neously. It  does  not  appear  that  either  man  or  other 
domestic  animals  except  those  noted  can  communicate 
it.  Only  about  15  per  cent,  of  those  bitten  develop  the 
disease,  and  bites  on  exposed  portions,  as  the  hands  and 
face,  are  most  dangerous.  Direct  inoculation  of  the 
saliva  will  also  produce  the  affection. 

The  stage  of  inoculation  in  man  is  usually  from 
twenty  to  fifty  days,  sometimes  three  months  or  even 
more.  During  this  time  the  wound  heals.  The  active 
symptoms  are  usually  announced  by  irritation  of  the 
scar,  nervousness,  anxiety,  and  loss  of  appetite  ;  and  in 
a  day  or  so  a  sense  of  constriction  in  the  muscles  of 
deglutition  and  respiration  sets  up.  These  symptoms 
are  aggravated  by  noises,  currents  of  air,  and  excite- 
ment of  any  kind.  Swallowing  soon  becomes  impos- 
sible. A  dreadful  terror  fills  the  mind  ;  later  convul- 
sions, and  soon  paralysis  and  death,  follow. 

Paroxysms  of  delirious  raving  and  violent  struggling 
occur  at  varying  intervals  in  the  earlier  stage  of  the 
attack  ;  later  on,  from  exhaustion,  they  may  diminish 
or  cease.  Death  usually  takes  place  by  the  third  day, 
the  mind  remaining  clear  to  the  very  last. 

Treatment.  —Immediately  upon  the  infliction  of  the 

78 


EPILEPSY — APOPLEXY.  79 

bite  excision  and  cauterization  should  be  employed,  as 
in  snake-bite.  If  possible,  as  a  precaution,  the  patient 
should  be  sent  to  an  institute  for  inoculation  with  the 
Pasteur  lymph,  which  has  shown  signal  value  in  pre- 
venting the  outbreak. 

When  the  attack  has  developed,  death  is  inevitable. 
Palliative  treatment  in  the  way  of  quiet,  in  a  dark 
room,  with  morphin,  bromids,  chloroform,  restraints,  is 
all  that  can  be  done. 

EPILEPSY. 

In  sudden  attacks  of  convulsions  or  unconsciousness 
application  is  made  to  the  nearest  person  for  informa- 
tion ;  hence  a  general  knowledge  is  desirable.  The 
commonest  cause  of  such  condition  in  the  adult  is  epi- 
lepsy. If  any  history  can  be  obtained,  it  will  serve  to 
explain  the  occurrence,  but  this  is  often  impossible  at 
the  moment.  In  most  forms  of  epilepsy  the  patient 
falls,  without  warning  or  screaming,  and  writhes  on  the 
ground,  with  bluish  countenance  and  open,  prominent 
eyes,  convulsive  movements  of  lips  and  cheeks,  as  well 
as  of  the  whole  body.  Often  the  tongue  is  bitten  and 
a  bloody  foam  appears  at  the  lips  and  nostrils.  Con- 
sciousness is  usually  regained  in  a  few  minutes,  but  the 
patient  does  not  become  rational  for  a  half-hour  or  so. 
The  diagnosis  of  the  attacks  is  the  only  point  of  in- 
terest, as  they  are  almost  never  fatal,  and  require  no 
treatment  at  the  time  except  to  prevent  the  patient 
from  injuring  himself.  Some  hard  object  at  hand 
should  be  pressed  into  the  mouth  to  prevent  injury  to 
the  tongue,  while  his  struggles  are  restrained. 

APOPLEXY. 

This  is  a  much  more  serious  affair.  Here,  too,  the 
patient  falls  unconscious,  but  without  convulsive  move- 
ments. The  body  is  quiet,  the  pulse  slow,  and  breath- 
ing usually  labored ;  eyes  closed  and  irresponsive  to 
light.     Consciousness   does   not   return    for   hours,   and 


80  EMERGENCIES. 

the  patient  cannot  be  roused.  Death  may  take  place 
immediately.  In  such  patients  found  after  falling  the 
condition  may  be  mistaken  for  alcoholic  intoxication, 
and  though  the  two  conditions  may  be  combined  in  the 
same  patient,  the  odor  of  the  breath  and  other  general 
surroundings  will  aid  in  distinguishing.  The  imme- 
diate treatment  of  apoplexy  consists  in  the  application 
of  cold  to  the  head  while  the  patient  lies  recumbent, 
until  he  can  be  removed  to  a  convenient  shelter  and 
put  under  the  care  of  a  physician. 

SUNSTROKE. 

Often  the  patient  so  stricken  falls,  but  usually  con- 
sciousness is  not  immediately  lost.  The  patient  is 
dazed,  greatly  prostrated,  perhaps  irrational,  and  soon 
becomes  insensible,  although  it  is  possible  to  rouse  him. 
The  temperature  is  usually  high,  and  the  pulse  quick 
and  feeble.  Alcoholism  may  be  combined  with  this 
condition,  and  the  two  may  be  confused.  As  in  apo- 
plexy, the  diagnosis  is  aided  by  the  odor  of  the  breath 
and  by  the  general  surroundings. 

The  immediate  treatment  of  sunstroke  is  the  appli- 
cation of  cold  cloths  and  ice-bags  to  the  head,  shelter 
from  the  heat,  and  prompt  transference  to  the  nearest 
hospital  or  similar  refuge,  and  immediate  medical  at- 
tention. A  hypodermic  injection  of  strychnin  is  often 
a  good  step  at  first  call. 

FOREIGN   BODIES   IN   THE   EYE. 

Foreign  bodies  often  lodge  in  the  eye  on  the  street, 
and  the  attention,  even  perhaps  of  the  nearest  person,  is 
sought  to  effect  their  removal.  Sometimes  such  bodies 
may  be  wiped  off  of  the  inverted  lid  with  one  end  of 
a  handkerchief  rolled  up  into  a  thread  or  cord.  The 
lid  is  everted  by  pressing  on  it  with  a  probe  or  lead- 
pencil  while  drawing  upward  on  the  eyelashes. 

When  the  foreign  body  is  forced  into  the  tissue  of  the 
cornea  or  sclerotic  coat,  the  patient  should  be  referred 


FOREIGN    BODIES    IN    THE    EAR    AND    AIR-PASSAGES.  01 

to  an  oculist,  as  some  troublesome  abrasion  will  likely 
be  left.  A  few  drops  of  a  solution  of  morphin,  one  grain 
to  one-half  ounce  of  distilled  water,  will  relieve  the  pain 
in  the  eye  due  to  the  irritation  from  these  bodies. 

FOREIGN   BODIES  IN  THE    NOSE. 

The  attention  of  the  dentist  will  rarely  be  called  to 
troublesome  foreign  bodies  in  the  nose,  but  occasionally 
a  neglected  case  will  be  encountered.  Children  push 
beans,  small  coins,  pebbles,  and  other  similar  articles 
up  the  nose,  but  commonly  no  harm  results  for  even 
days  afterward,  and  plenty  of  time  may  be  allowed  to 
get  skilled  aid.  To  remove  such  objects  a  flexible  ex- 
tractor with  a  short  hook  or  shoulder  will  often  suffice. 
At  times  it  may  be  necessary  to  push  small  objects  into 
the  pharynx  and  then  remove  them  through  the  mouth. 
F'ixed  bodies  may  require  excision. 

FOREIGN  BODIES  IN  THE  EAR  AND  AIR=PASSAGES. 

Foreign  bodies  in  the  ear  may  usually  be  washed 
out  with  a  syringe  and  warm  water. 
Foreign  bodies  occasionally  lodge  in  the  pharynx. 

Sometimes  such  a  body  is  a  large  lump  of  imperfectly 
masticated  food,  which  may  be  so  placed  as  to  occlude 
the  glottis  and  produce  suffocation.  Troublesome,  but 
not  so  promptly  dangerous,  symptoms  may  arise  from 
coins,  marbles,  etc.,  carelessly  put  into  the  mouth  by 
children.  Usually  the  finger  thrust  into  the  pharynx 
will  remove  the  larger  bodies.  Fish-bones  and  bits  of 
wood  sometimes  lodge  in  the  throat  and  produce  great 
annoyance  ;  commonly  they  can  be  seen  in  good  light 
and  removed  with  small  dressing  forceps.  Many  sub- 
stances temporarily  lodged  in  the  pharynx  pass  into  the 
stomach  or  are  pushed  down  and  either  pass  out  by  the 
bowel,  or  if  not,  may  be  extracted  through  the  abdomen. 
Foreign  bodies  passing  into  the  larynx  and  tra- 
chea produce  most  serious  and  alarming  symptoms, 
from  which  there  is  no  safe  relief  until  the  body  is  either 

6 


82  EMERGENCIES. 

expelled  or  extracted.     The  accident  is  announced  by 

violent  and  unintermitting  coughing,  and  symptoms  of 

impending  sufifocation,   which,   indeed,   may  take  place 

at  any  moment.      Sometimes  inverting  the   body  head 

downward  and  shaking  or  striking  on  the  back  will  give 

relief ;   if  not,    prompt    measures   should    be    taken  for 

tracheotomy. 

BURNS. 

Burns  and  scalds  produce  practically  the  same  lesion — 
usually  the  scalds  are  more  superficial,  and  commonly, 
too,  more  extensive  proportionately. 

This  accident  is  the  most  common  fatality  among  sur- 
gical emergencies,  and  its  gravity  depends  more  upon  the 
extent  of  surface  destroyed  than  upon  the  depth  of  the 
burn.  Burns  are  defined  as  presenting  three  degrees  : 
(i)  Erythema  or  congestion  of  skin  ;  (2)  vesication ;  (3) 
destruction  of  skin  and  deeper  tissues  to  an}-  extent. 

In  extensive  burns  there  is  usually  profound  shock, 
during  which  the  majority  of  fatal  cases  terminate. 

After  thirty-six  hours  the  prognosis,  even  in  most  ex- 
tensive burns,  becomes  much  more  favorable.  Septic 
infection  and  extensive  suppuration  are  fatal  sometimes 
in  those  who  survive  the  shock.  Other  things  being 
equal,  the  old  and  very  young  present  the  most  unfavor- 
able prospect.  Burns  that  involve  one-fourth  or  more  of 
the  cutaneous  surface  even  to  the  first  degrees  are  almost 
always  fatal.  Later  on  extensive  suppuration  produces 
exhaustion  and  disease  of  the  kidney. 

Symptoms. — These  vary  with  the  extent  as  well  as 
with  the  degree  of  burn.  Unless  shock  be  severe,  the 
pain  is  usually  very  harrowing,  perhaps  resisting  any 
opiate.  Swelling  of  the  skin  with  either  reddening  and 
a  few  scattered  blebs  or  extensive  vesication  with  large 
and  deep  blisters,  and,  in  fatal  cases,  stupor  and  death, 
soon  terminate  the  case. 

In  the  third  degree  the  structures  may  be  burned 
deeply  and  even  the  bones  be  charred. 

Treatment. — When  there  is  severe  shock,  stimulation 


SUMMARY.  83 

with  ammonia,  whisky,  strychnin,  and  ahnost  always 
opium,  in  the  form  of  morphin  hypodermically,  are  the 
immediate  indications.  If  the  extremities  become  cold, 
hot  bottles  are  of  value.  After  the  shock  is  past  good 
nourishing  food  is  of  great  importance. 

Local  treatment  is,  however,  the  great  measure  of 
relief.  In  moderate  burns  applications  of  soft  cotton 
cloths — part  of  an  old  sheet — freely  wetted  in  a  sat- 
urated solution  of  bicarbonate  of  soda  are  useful.  Over 
this  a  layer  of  dry  absorbent  cotton  helps  to  keep  out 
the  air. 

In  more  severe  burns,  where  there  is  extensive  vesica- 
tion, it  is  best  to  open  the  blisters,  and  if  there  be  time 
and  the  strength  of  the  patient  justifies  it,  irrigate  with 
I  :  1500  solution  bichlorid  of  mercury,  and  apply  the 
solution  of  soda,  boric  acid,  or  salic\-lic  acid.  In  the 
country,  and  indeed  in  all  severe  burns  when  shock  is 
extreme,  the  carron  oil  (equal  parts  of  lime-water  and 
linseed  oil)  is  often  hurriedly  used  with  the  best  results 
as  to  relief  from  pain,  although  neither  aseptic  nor 
agreeable  of  odor. 

Usually  the  pain  has  almost  disappeared  by  the  third 
day,  when  stimulating  ointments  may  be  substituted. 
Extensive  sloughs  may  be  cut  away,  and  the  surfaces 
irrigated  daily  with  bichlorid  solutions.  Later,  skin- 
grafting  may  be  of  service,  while  vicious  contractions  of 
tendons  and  the  webbed-like  prolongations  of  scar-skin 
seen  about  the  elbow,  neck,  and  fingers  must  be  guarded 
against  with  all  possible  care. 


SUMMARY. 

Hydrophobia  in  man  is  derived  from  the  feline  and 
canine  species.  It  develops  only  in  about  15  per  cent,  of 
those  bitten.  Incubation  period  is  from  thirty  to  ninety 
days.  Early  symptoms  are  constriction  in  the  throat, 
dread  of  swallowing,  convulsions,  and  exhaustion.  Death 
inevitable  ;  duration,  two  to  four  days.    Preventive  treat- 


84  EMERGENCIES. 

ment  by  excision  of  the  bite  and  cauterization  indicated. 
Inoculation  by  the  Pasteur  method  when  possible. 

Epilepsy  differs  from  apoplexy  and  sunstroke  in  the 
convulsions  and  activity  during  the  attack  and  the 
usually  easy  return  to  consciousness,  with  the  history 
often  of  many  previous  attacks. 

In  apoplexy  the  patient  is  motionless,  and  paralysis 
is  usually  present. 

In  sunstroke  the  temperature  is  high  and  the  pulse 
quick  and  weak. 

Foreign  bodies  in  the  nose  produce  no  urgent  symp- 
toms ;  in  the  phajynx^  where  they  obstruct  the  air-pass- 
ages, lumps  of  food  or  large  coins  can  usually  be  removed 
by  the  finger.  When  in  the  larynx^  tracheotomy  is 
usually  required. 

B2ir7is  are  the  commonest  fatal  accident.  They  are  of 
three  degrees.  The  most  fatal  period  is  during  shock. 
Treatment  is  morphin  internally  and  soothing  applica- 
tions and  dressings  locally.  Later  supportive  treatment 
and  encouragement  of  granulation.  Vicious  cicatrices 
must  be  watched  for. 


CHAPTER   XII. 

HEMORRHAGE. 

Hemorrhage,  even  to  the  experienced,  is  always  a 
matter  of  annoyance  and  concern  ;  not  alone  because  it 
may  not  yield  to  ordinary  measures,  but  because  any 
loss  of  blood  is  to  many  enfeebled  patients  a  serious 
misfortune,  and  to  even  the  robust  undesirable.  But 
to  the  beginner,  even  minor  blood-flow  is  usually 
a  terror,  because  any  delay  in  its  control  alarms  the 
patient  and  friends,  as  well  as  unnerves  the  surgeon. 
If,  however,  the  operator  will  bear  in  mind  that  any  ex- 
ternal accessible  hemorrhage  can  safely  be  managed  by 
a  little  patience,  and  will  but  think  over  the  best  and 
simplest  plan,  he  will  rarely  experience  any  serious  an- 
noyance. Concealed  and  internal  hemorrhages  are,  how- 
ever, often  disastrous  in  spite  of  the  best  directed  efforts. 

Ordinarily  hemorrhages  may  be  divided  into — (i)  Pri- 
mary ;  (2)  reactionary ;  (3)  secondary^  whether  arterial 
or  venous.  The  blood  in  arterial  hemorrhage  is  a  bris^ht 
red,  and  appears  in  jets,  intermitting  and  synchronous 
with  each  heart-beat,  usually  continuing,  unless  arrested, 
until  syncope  arises.  Small  arteries  often  pour  a  con- 
tinuous flow.  As  a  rule,  venous  hemorrhage  is  a  steady, 
dark-colored  current,  soon  stopping  of  itself 

Capillary  bleedijig  is  an  oozing  of  a  bright,  arterial- 
like  blood,  without  spurt  and  often  persisting  for  many 
hours. 

Primary  hemorrhage  succeeds  the  division  of  the  ves- 
sels ;  usually,  if  arterial,  it  requires  to  be  arrested  by 
some  agent ;  it  ceases  of  itself  from  small  arteries  and 
most  veins.  Arterial  hemorrhage,  even  when  from  small 
vessels,  usually  requires  some  steps. 

Reactionary  lieniorrJiagc  comes  on  when  the  clot  that 


86  HEMORRHAGE. 

first  forms  in  the  veins  is  dislodg^ed  bv  the  strengthened 
heart.  While  the  same  is  true  of  the  arteries  and  capilla- 
ries, as  the  reaction  following  chloroform  and  shock,  yet 
sometimes  it  is  due  to  a  slipping  ligature  or  an  overlooked 
vessel.  Usually  reactionary  hemorrhage  comes  on  twelve 
to  twenty  hours  after  primary. 

Secondary  Jiemorrhage  is  due  to  slough  of  vessel  or  to 
premature  separation  of  a  ligature.  It  is  seen  six  to 
fourteen  days  after  injury,  due  chiefly  to  infection  of  the 
wound  and  extension  of  infection  to  the  vessel,  almost 
always  an  artery. 

Symptoms  of  hemorrhage  are  local  and  constitutional. 

The  local  symptoms  need  no  description.  When  either 
a  large  vein  or  artery  is  severed,  there  is  a  profuse  rush 
of  blood,  and  unless  proper  treatment  is  instituted,  death 
may  speedily  take  place.  In  injuries  of  smaller  vessels 
the  flow  continues  until  pressure  or  syncope  arrests  it. 

Constitutional  symptoms  of  hemorrhage  are  of  highest 
importance,  especially  when  the  bleeding  is  concealed. 
As  the  loss  goes  on  the  pulse  first  becomes  quicker,  the 
face  pale,  the  respirations  shallow  and  hurried.  If  the 
loss  is  rapid  and  progressive,  soon  shortness  of  breath, 
flashes  of  light,  roaring  in  the  ears,  and  fainting  and 
syncope  are  added.  If,  as  often  happens,  the  flow 
ceases  during  syncope,  when  the  heart  action  is  very 
weak  the  hemorrhage  may  not  recur  at  once  or  even 
later.  When  a  large  vessel  is  divided,  however,  the 
blood  continues  to  escape,  unconsciousness  persists,  and 
death  follows,  either  with  convulsions  or  by  prompt 
heart  failure. 

When  the  flow  is  less  prompt,  syncope  is  recovered 
from,  but  recurs,  the  dyspnea  becoming  more  distressing. 
Convulsions  come  on  and  death  soon  ensues. 

Slighter  hemorrhages  are  arrested  by  coagulation  of 
the  blood  in  the  vessels,  which  is  favored  by  laceration 
of  their  lining  at  the  time  of  injury  ;  cold  and  the  air 
are  helps  in  this  coagulation. 

Diagnosis. — Open  hemorrhage  proclaims  itself.     In 


TREATMENT.  8/ 

concealed  hemorrhage  the  diagnosis  is  made  by  the 
symptoms  given,  and  often  by  clots  seen,  and  in  cases 
of  doubt  by  removing  stitches  or  perhaps  the  introduc- 
tion of  an  aspirator. 

Treatment. — In  most  cases  of  external  hemorrhage 
the  treatment  is  promptly  local,  and  the  matter  is 
simple.  Elevation  of  the  part,  the  application  of  cold, 
pressure  with  sponges  wrung  out  of  hot  water  for  capil- 
lary oozing,  compresses  over  obstinate  bleeding  that 
cannot  be  located  by  general  methods. 

The  application  of  ligatures,  either  tied  directly  on 
the  bleeding  vessel  after  it  is  picked  up  on  the  forceps, 
or  carried  by  a  needle  underneath  the  bleeding  spot  and 
then  tied,  is  the  most  acceptable  method.  The  ligature 
for  ordinary  cases  should  be  either  No.  i  or  2  catgut. 
Silk  is  less  satisfactor)',  as  it  is  more  likely  to  become  a 
foreign  body.  The  ligature  should  be  tied  in  a  double 
knot  and  the  thread  passed  under  twice  in  the  first  tie. 

Small  arteries  may  be  controlled  by  torsion,  by  grasp- 
ing the  vessel  with  the  forceps,  drawing  it  well  out,  and 
twisting  it  three  or  four  times.  This  ruptures  the  inner 
coat  and  causes  coagulation. 

Acupressure,  or  the  passing  of  a  pin  underneath  the 
vessel,  and  then  making  compression  by  twisting  the 
pin  or  applying  a  figure-of-eight  ligature,  is  now  rarely 
employed.  When  the  means  suggested  will  not  control 
inaccessible  bleeding  the  wound  should  be  enlarged  freely 
so  as  to  render  the  spots  accessible,  or  compresses  charged 
with  styptics  often  succeed,  temporarily  at  least. 

The  most  commonly  employed  chemical  styptic  is  the 
salt,  or  a  solution  of  subsulphate  of  iron,  either  on  a 
piece  of  gauze  packing  or  directly  to  the  spot.  The 
chlorid  of  adrenalin  has  recently  proved  a  valuable  styp- 
tic, applied  locally  in  a  solution  of  i  :  3000.  Such  meas- 
ures are  objectionable  because  a  slough  forms,  which  is  a 
favorable  site  for  infection,  and  primary  union  is  always 
prevented.  These  measures  are  chiefly  applicable  to 
inaccessible  wounds  in  the  mouth  or  in  the  bone. 


56  HEMORRHAGE. 

When  a  ligature  has  slipped  in  reactionary  hemorrhage 
or  sloughs  occur  in  the  secondary  form,  religation,  and 
perhaps  a  new  wound  to  find  the  vessel  may  become 
necessary.  Free  enlargement  of  the  wound  is  to  be 
made  when  needed  to  reach  the  source  of  bleeding. 

When  excessive  hemorrhage  has  left  the  patient  ex- 
hausted, the  introduction  of  the  normal  salt  solution — 
a  dram  of  sterilized  fine  salt  to  a  pint  of  a  distilled  water 
— should  be  practised,  either  directly  into  a  vein,  or, 
as  is  more  commonly  employed,  into  the  cellular  tissue 
of  the  legs,  arms,  or  under  the  mammary  gland.  A 
medium-sized  aspirating  needle  secured  to  the  nozzle  of 
a  clean  fountain  syringe  will  answer  as  an  apparatus,. 
About  lo  to  20  ounces  of  the  solution  at  100°  F, 
is  the  proper  amount,  repeated  in  a  few  hours  if 
indicated. 

The  constitutional  treatment  of  acute  hemorrhage  is 
hardly  to  be  considered,  though  after  control  the  admin- 
istration of  fluids,  stimulants,  as  whisky  and  strychnin, 
may  be  indicated. 

In  concealed  or  inaccessible  hemorrhage  much  the 
same  treatment  may  be  tried,  though  it  offers  little  pros- 
pect. 

Hemophilia. — This  is  a  condition  in  which,  due  to 
disease  of  the  blood-vessels  as  well  as  to  a  want  of  coag- 
ulability of  the  blood,  the  oozing  persists  in  spite  of  all 
attempts  at  control.  It  is  wholly  a  constitutional  condi- 
tion, rare  in  this  country,  though  common  in  Switzerland 
and  other  parts  of  Europe. 

Symptoms. — Usually  the  condition  is  hereditary,  and 
presents  a  history  of  troublesome  bleeding  from  baby- 
hood, as  well  as  a  family  history  of  the  condition.  The 
child  bleeds  at  the  slightest  cut,  the  oozing  persisting 
perhaps  for  days  in  spite  of  all  applications  and  pressure. 
It  may  cease  only  on  syncope,  and  then  often  recurs. 
Extraction  of  a  tooth  is  perhaps  the  most  common  cause 
of  uncontrollable  hemorrhage  in  this  condition,  and  often 
results  in  exhaustion  and  death  after  perhaps  a  week  or 


NASAL    HEMORRHAGE.  89 

more  of  bleeding.  With  such  a  history  no  operation 
should  be  undertaken  so  long  as  avoidable,  and  even  the 
simplest  wounds  are  to  be  regarded  as  dangerous.  The 
author  has  twice  seen  death  follow  extraction  of  a  tooth 
despite  most  skilful  treatment. 

Treatment. — Preventive  treatment,  in  avoiding  the 
opportunity  for  injury  or  wound,  should  never  be  forgot- 
ten. When  a  wound  is  made  it  is  usually  better  to  have 
it  free,  so  that  the  vessels  may  contract  and  pressure  be 
applied  to  advantage.  Styptics  on  the  wound  should  be 
early  used.  It  is  found  that  the  coagulability  of  the 
blood  progressively  diminishes  as  the  flow  continues,  and 
hence  the  prospect  of  a  cessation  is  less  favorable,  other 
things  being  equal.  Rest  of  the  patient  and  quietude  bj' 
opium  will  assist  the  other  measures.  If  the  vessel  can 
be  seen,  it  should  be  tied,  of  course,  but  usually  neither 
ligature  nor  forceps  will  avail.  In  one  instance  seen  in 
consultation,  the  attending  physician  had  lanced  a  small 
abscess  in  the  neck,  and  though  we  transfixed  the  margin 
of  the  wound  with  a  needle,  and  wound  a  figure-of-eight 
ligature  about  it,  the  oozing  continued  and  in  a  few  days 
sepsis  and  acute  anemia  carried  the  child  off. 

NASAL  HEMORRHAGE. 

Hemorrhage  from  the  nose,  or  epistaxis,  is  a  very  com- 
mon occurrence  in  children,  and  not  rarely  also  in  voung 
adults.  It  may  arise  from  falls  and  blows,  but  frequently 
comes  on  without  any  apparent  cause.  In  children  it 
rarely  requires  any  other  attention  than  domestic  reme- 
dies, although  sometimes  the  surgeon  is  called.  In  the 
aged,  where  the  loss  of  blood  is  more  serious,  greater 
emergency  arises.  In  elderly  people,  too,  some  actual 
lesion  is  much  more  likelv  to  be  found. 

Treatment. — Ordinarily  bathing  the  forehead  and  face 
will  control  the  bleeding.  Finely  pounded  ice  applied 
in  a  handkerchief  to  the  bridge  of  the  nose  will  usually 
stop  the  bleeding  in  a  few  minutes.  The  application 
of  a  solution  of  the  chlorid  of  adrenalin — i  :  3000 — by 


go  HEMORRHAGE. 

a  mop  or  sprayed  from  an  atomizer  answers  well  in 
troublesome  cases.  If  more  energetic  measures  are 
indicated,  the  spray  of  Monsel's  solution  of  iron — 
I  part  to  3  parts  of  water — up  into  the  nostril  will 
almost  always  control  the  bleeding.  If  this  fails,  the 
posterior  nares  may  be  plugged  by  passing  a  small- 
sized  hollow  English  flexible  catheter  back  through 
the  nose  into  the  throat.  The  catheter  should  carry  a 
stout  silk  thread  which  is  brought  out  of  the  mouth  by 
the  fingers  or  a  dressing  forceps.  A  pledget  of  gauze 
the  size  of  the  end  of  the  little  finger,  saturated  with 
dilute  Monsel's  solution,  is  then  drawn  tightly  against 
the  posterior  opening,  and  tied  to  another  pledget  at  the 
nostril  opening.  This  plug  should  be  removed  in  twenty- 
four  hours  and  the  canal  washed  out  with  antiseptics. 
Such  extreme  measures  should  not  be  resorted  to  until 
other  treatment  has  been  faithfully  tried,  because,  in 
addition  to  causing  great  discomfort,  there  is  always 
some  risk  of  sepsis. 


SUMMARY. 

Primary  external  bleeding,  no  matter  how  severe,  can 
almost  always  be  controlled  in  time  to  save  life  if  proper 
means  are  at  hand.  Recurrent  hemorrhage  is  due  to 
overlooked  vessels  or  dislodged  clots.  Secondary  hem- 
orrhage is  due  to  slough  of  an  artery  or  a  large  vein  from 
infection.  Hemorrhage  is  controlled  by  pressure  or  by 
a  tourniquet.  Then  the  blood-vessels  are  secured  and 
ligated  with  catgut.  Small  vessels  may  be  twisted. 
Pressure  with  compresses  controls  oozing.  When  hem- 
orrhage is  concealed,  the  symptoms  are  pallor,  coldness 
of  the  extremities,  feeble  pulse,  clamoring  for  fresh  air, 
and  fainting  or  syncope.  The  treatment  of  concealed 
hemorrhage  is  recumbency,  cold  to  the  surface,  injection 
of  normal  salt  solution.  In  recurrent  hemorrhage,  if 
severe  enough,  the  dressing  should  be  removed  and  the 
bleeding  vessel    found.     In   secondary  hemorrhage  the 


SUMMARY.  91 

bleeding  vessel  should  be  found,  or  else  the  trunk  ligated 
through  the  sound  tissues  on  the  heart  side. 

The  hemorrhagic  diathesis  is  not  common  in  this 
country,  and  is  usually  inherited.  It  makes  all  wounds 
dangerous,  particularly  the  extraction  of  teeth.  It  is  a 
contraindication  to  all  avoidable  operations.  When 
bleeding  occurs,  pressure,  styptics,  recumbency,  and,  of 
course,  the  ligature,  are  appropriate. 

Bpistaxis  is  usually  controlled  by  the  application  of 
cold  to  the  bridge  of  the  nose.  When  necessary,  a  spray 
of  the  diluted  Monsel's  solution  of  iron  or  a  pledget  of 
gauze  saturated  with  this  solution  pushed  into  the  nose 
will  usually  answer.  If  the  hemorrhage  persists,  resort 
may  be  had  to  plugging  both  the  posterior  and  anterior 
outlets,  taking  into  consideration  the  risks  of  sepsis  and 
ulceration. 


CHAPTER    XIII. 
TUMORS. 

The  tumors  of  the  skin  and  of  the  bony  and  glandu- 
lar structures  about  the  face  and  neck  are  of  nearly  every 
variety.  It  is  therefore  necessary  for  the  student  of 
dentistry  to  have  an  idea  of  the  growth  and  morphology 
of  tumors  in  general. 

By  a  tumor  is  meant  a  circumscribed  enlargement  of 
new  livinof  tissues.  The  s;rowth  is  non-inflammatorv  and 
without  physiologic  function. 

The  term  tumor  is  often  colloquially  applied  to  any 
abnormal  nodule  or  prominence,  but  pathologically  the 
term  comprehends  a  neoplasm.  Ordinarily  inflammatory 
swellings  indicate  their  character  readily.  The  more 
obscure,  though  sometimics  delaying  diagnosis,  soon  cease 
to  grow  and  often  decrease  in  size  or  wholly  disappear. 

Cause  and  Pathology. — Tumors  originate  from  pre- 
existing emb7yo7iic  cells.  Usually  these  cells  are  con- 
genital, though  there  is  reason  to  believe  the  original 
matrix  of  a  tumor  is  occasionally  developed  after  birth, 
or  even  late  in  life,  as  the  result  of  some  microbic  action. 
These  cells  may  be  fixed  or  detached  from  the  primary 
matrix  and  carried  b\'  the  circulation  to  another  site, 
where  a  similar  tumor  develops.  These  new  growths, 
whether  benign  or  malignant,  always  resemble  in  part 
some  normal  tissue,  although  as  a  mass  they  are  abnormal 
in  tissue  formation.  It  is  easy  to  understand  that,  as  the 
essential  growth  of  the  tumor  must  arise  from  the  cells 
of  embryonic  or  abnormal  tissue,  in  its  growth  it  will 
still  present  in  its  new  construction  the  product  of  these 
new  cells.  These  cells  are  variously  derived  from  the 
different  layers  of  the  embryo,  and  they,  of  course,  per- 
sist in  their  own  genetic  identity  throughout. 

92 


DIAGNOSIS — CLASSIFICATION.  93 

Benign  tumors  are  those  that  do  not  tend  to  ulceration 
and  the  production  of  blood  changes,  and,  except  from 
large  size  and  pressure  upon  important  organs,  do  not 
tend  to  shorten  life.  These  growths  are  primajy  in 
origin,  and  often  so  closely  resemble  the  surrounding 
tissues  from  which  they  spring  that  even  the  microscope 
cannot  always  determine  the  distinction.  From  this 
resemblance  they  are  termed  homologous. 

Secondary  tumors  are  usually  7naligna7it  and  are  not 
microscopically  like  the  surrounding  tissues.  They  are 
termed  heterologous.  Their  cells  are  immature  and  in 
some  varieties  the  constituency  of  the  entire  growth  is 
distinctly  embryonic. 

The  growth  of  tumors  is,  as  just  stated,  by  the  prolif- 
eration of  the  matrix  cells,  as  in  all  normal  development 
and  repair.  The  benign  are  usually  single  and  often 
encapsulated  and  movable.  They  are  of  slow  growth  and 
painless,  except  when  pressing  upon  sensitive  structures. 

Malignant  tumors  often  multiph-  in  the  form  of  sec- 
ondary deposits.  They  are  usually  fixed  in  the  surround- 
ing tissues  by  infiltration,  and  grow  rapidly.  They 
are  essentialh-  painful,  and  early  show  a  tendency  to 
invade  surrounding  heterologous  structures.  Though 
it  is  true  that  many  tumors  for  years  looked  upon  as 
benign  may  later  develop  a  malignant  course,  it  is  prob- 
able that  the  embryonic  cells  were  latent  in  the  growth 
from  its  origin.  It  is  not  clear  with  our  present  knowl- 
edge of  pathology  how  a  transformation  could  occur, 
although  the  future  study  of  bacterial  agencies  may  ex- 
plain it. 

Diagfnosis. — The  determination  of  the  character  of 
a  tumor  is  controlled  by  the  situation  of  the  tumor,  the 
age  and  sex  of  the  patient,  and  the  history,  appearance, 
and  character  of  its  growth,  aided  by  the  microscope. 

Classification. — Tumors  are  classified  with  reference 
to  their  origin  and  structure,  and  it  will  interest  us  as 
dentists  practically  to  take  up  only  those  connected  with 
the  mouth  and  jaws,  although  these  will  not  represent 


94  TUMORS. 

every  variety,  as  many  tissues  of  the  body  are  not  here 
involved.  However,  the  definitions  of  the  various  forms 
here  taken  up  will  clearly  indicate  the  nomenclature  and 
pathology  of  all  important  neoplasms. 

Tumors  chiefly  encountered  by  the  dentist   are,   for 
practical  purposes,  best  classified  as : 

1.  Papilloma  or  warty  growth. 

2.  Adenoma  or  glandular  growth. 

3.  Fibroma  or  fibrous  growth. 

4.  Chondroma  or  cartilaginous  growth. 

5.  Lipoma  or  fatty  growth. 

6.  Osteoma  or  bony  growth. 

7.  Odontoma  or  tooth  growth. 

8.  Angioma  or  blood-vessel  growth. 

9.  Sarcoma  or  malignant  growth. 

10.  Carcinoma  or  malignant  growth  (cancer). 

11.  Cystoma  or  cystic  growth. 

12.  Retention  cysts — not  growths  at  all. 

It  is  quite  common  to  find  tumors  composed  of  two  or 
more  kinds  of  tissue,  as  adenofibroma,  adenocystoma,  etc. 

PAPILLOMA. 

This  growth  is  an  enlarged  epithelial  papilla,  and  is 
commonly  termed  wart,  horn,  etc.  It  consists  of  an 
outo-rowth  from  the  epithelial  cells,  with  a  network  of 
connective  tissue.  It  is  found  chiefly  on  the  skin  and 
mucous  membrane,  and  is  usually  multiple  and  some- 
times numerous.  That  seen  on  the  skin,  as  a  rule,  is 
hard,  and  chiefly  observed  in  youth,  and  is  of  little 
importance.  That  seen  on  the  mucous  membrane  of 
the  genital  organs  is  soft  in  variety,  and  indicates  un- 
cleanliness— perhaps  specific  discharges.  Certain  pap- 
illomatous prolongations  in  the  bladder  and  in  the 
rectum  cause  hemorrhage  and  other  pathologic  mani- 
festations. Similar  growths  in  the  ovaries  and  over  the 
peritoneum  have  a  tendency  to  malignancy. 

Papillomata  interest  us  as  dentists  chiefly  in  the  hyper- 


ADENOMA.  95 

trophied  papilla  seen  on  the  face.  This  condition  is 
more  frequently  observed  in  advanced  life,  and  the 
growth  may  have  a  flattened  or  sessile  base  or  a  pe- 
dunculated attachment,  or  it  may  be  a  horn-like  proc- 
ess. 

Warty  growths  are  not  common  inside  the  mouth, 
but  are  occasionally  seen.  Many  of  these  papillomata 
present  no  tendency  to  malignancy,  although  ulceration 
and  irritability  are  frequently  noticed.  Some,  however, 
after  years  of  quiescence  have  taken  on  evidence  of  car- 
cinoma of  the  epithelial  type. 

The  diagnosis  of  papilloma  is  usually  easily  made. 
To  determine  against  malignant  tendency  is  not  always 
easy,  and  doubtful  cases  should  be  promptly  extirpated. 

Treatment. — The  treatment  of  warts  in  young  per- 
sons need  rarely  be  energetic,  as  the  removal  of  irrita- 
tion will  usually  be  followed  by  the  disappearance  of 
the  growth.  When  treatment  is  desired,  the  growth 
may  be  snipped  off"  vv^ith  scissors  or  removed  with  re- 
peated cauterizations  with  chromic  acid,  first  scarifying 
the  wart  until  it  bleeds,  and  applying  the  moistened 
crystals  of  the  acid.  This  step  repeated  every  two  days 
for  a  week  will  usually  succeed.  Later  in  life  extirpa- 
tion by  free  incision  should  be  employed  in  all  irritated 
or  troublesome  papillomata,  without  waiting  to  see 
what  course  they  may  take. 

ADENOMA. 

Practically  this  tumor  is  the  outgrowth  of  some  gland- 
ular tissue  ;  occasionally  the  whole  gland  is  involved. 
While  these  new  structures  closely  resemble  the  tissue 
from  which  they  spring,  usually  many  of  the  elements 
of  the  gland  itself  are  not  found  in  the  neoplasm,  but 
an  excess  of  other  tissue  is  present.  Adenomata  are 
prone  to  recurrence,  aiid  not  rarelv  combine  the  ele- 
ments of  malignancy,  as  in  the  adenosarcoma.  They 
are  usually  encapsulated,  and  often  tend  to  cystic  degen- 
eration and  malienancv. 


96  TUMORS. 

Glandular  tumors  vary  greatly  in  size ;  though  usu- 
ally not  large,  they  occasionally  become  enormous. 
The  diagnosis  and  prognosis  of  these  growths  are  con- 
trolled largely  by  the  structures  in  which  they  are 
found. 

Adenomata  of  the  sweat-glands  are  not  common,  but 
are  seen  as  small  indurated  tumors  under  the  skin,  usu- 
ally multiple.  They  are  often  seen  on  the  face.  Ex- 
tirpation is  a  successful  treatment. 

Adenomata  of  mucous  membranes  are  seen  as  polypi 
in  the  nose  and  pharynx,  sometimes  attaining  consider- 
able size.  Not  all  such  growths  are  true  adenoids  by 
any  means,  but  many  consist  of  a  distinct  cell  growth ; 
others  are  hyperplastic  and  retention  cysts.  Adenoid 
growths  in  the  nasopharynx  and  in  the  antrum  of  High- 
more  at  times  take  on  a  malignant  tendency. 

The  diag"nosis  of  growths  of  this  character  in  the 
pharynx  and  nose  is  made  by  the  history  of  difficult 
breathing,  altered  voice,  cough,  and  discharge.  Usu- 
ally there  is  little  pain.  Inspection  with  suitable  light 
and  instruments  indicates  the  lesion. 

The  prognosis  is  usually  favorable ;  after  removal 
recurrence  is  rare. 

The  treatment  is  removal  with  snare  or  forceps  or 
thermocautery.  Troublesome  hemorrhage  sometimes 
follows,  but  pressure  and  cold  will  usually  control  it. 

Adenomata  of  the  tongue  and  the  parotid  gland  are 
not  at  all  common,  and  when  encountered,  require 
more  troublesome  and  difficult  operations  than  are  con- 
templated out  of  general  surgery. 

FIBROMA. 

This  tumor  is  formed  of  hard  tissue,  often  very 
dense,  disposed  about  the  vessels  and  nerves  of  the  part 
involved.  They  usually  are  surrounded  by  a  defined 
capsule.  They  may  be  found  in  any  tissue  of  the 
body,  in  the  glandular  and  functionating  organs  as 
well  as  in  the  muscles,  tendons,  and  periosteum.     They 


Perry's  Case  of  ADENOiMAXA. 


LIPOMA. 


97 


are  painless,  except  when  from  size  or  location  they 
press  on  vital  structures  or  nerves.  The  so-called 
keloid  and  the  fibroma  molluscum  are  examples  in 
the  skin.  Forms  of  polypi  and  growths  on  the  face 
as  well  as  in  tonsils  are  of  this  character.  Immense 
growths  are  seen  in  the  uterus  ;  usually  muscular  tissue 
is  interwoven  with  the  fibrous   in    the   lar2:er  tumors. 


Fig.  12. — Fibrocystic  tumor  of  parotid  region  (Nancrede). 

Such  growths  show  little  tendency  to  malignancy,  but 
when  the  situation  is  favorable  they  should  be  removed. 


LIPOMA. 

These  tumors  consist  of  masses  of  subcutaneous  fat^ 
always  superficial  and  encapsulated.  They  have  a  dim- 
pled, somewhat  indented  surface,  often  suggesting  a 
false  sense  of  fluctuation  ;  they  are  painless,  movable,, 
and  slow  growing,  without  tendency  to  ulceration  or 
malignancy,  and  require  treatment  only  when  unsightly 
or  in  the  way  of  the  clothing. 

Such  tumors  are  seen   not  infrequently  on  the  face, 
nose,  neck,  and  shoulders.     If  operation  is  undertaken 
at  all,  the  tumor  with  capsule  should  be  extirpated. 
r 


98  TUMORS. 

OSTEOMA. 

This  term  properly  belongs  to  the  growths  from  the 
center  of  the  bone  structure.  Exostoses  or  prominences 
on  the  surface  of  the  flat  and  long  bones  are  not,  strictly 
speaking,  osteomata.  These  growths  are  seen  in  the 
bones  of  the  face,  sometimes  symmetric,  but  usually 
unilateral,  and  in  the  long  bones  and  the  phalanges. 
They  grow  slowly,  and  are  thus  diagnosticated  from 
malignant  growths  in  bone,  which  are  usually  of  rapid 
progress,  generally  painful,  and  indicate  disturbance  in 
the  circulation  of  the  surrounding  skin.  Osteomata  do 
not  demand  surgery  except  when  pressure  or  other  inter- 
ference with  function  indicates  it. 

Disfiguring  growths  of  the  superior  maxillary  bone 
are  seen  often  to  be  of  large  size,  firm  in  structure,  and 
of  bony  origin.  Usually  they  offer  little  to  surgical 
skill.  When  interfering  with  function  or  comfort  re- 
moval is  indicated. 

A  symmetric  enlargement  of  the  facial  bones,  termed 
leontiasis,  is  frequently  seen.  It  begins  in  the  young 
adult,  and  is  apparently  associated  with  some  decay  of 
the  vital  forces,  as  it  usually  ends  in  death. 

A  symmetric  enlargement  of  the  whole  skeleton, 
noticeable  chiefly  in  the  face  and  hands  and  feet,  and 
termed  acromegaly,  is  worthy  of  a  passing  notice  here. 
It  is  very  rare  and,  like  leontiasis,  the  cause  is  not 
known.     There  is  no  treatment. 

CHONDROMA. 

This  tumor  is  composed  of  cartilaginous  structures. 
They  are  usually  multiple,  hard,  and  inelastic,  and  seen 
in  parts  of  the. body  where  cartilage  is  found.  Occasion- 
ally they  are  observed  about  the  jaws  and  sometimes  in 
the  tonsils.  They  are  painless,  and  usually  grow  slowly. 
They  are  irregular  and  often  nodular,  and  frequently 
recur  after  removal,  not  rarely  showing  malignant  indi- 
cations. When  feasible,  removal  is  indicated  by  enucle- 
ation, extirpation,  or  amputation. 


ODONTOMA. 


99 


ODONTOMA. 

This  is  a  tumor  developing  from  dental  tissue,  usually 
placed  abnormally.     They  have  four  sources  of  origin: 

(i)  From  the  enamel  organ^  often  as  large  epithelial 
cysts,  frequently  multilocular,  involving  large  parts  of 
the  jaw — usually  the  lower.  (2)  From  a  small  detitiger- 
ous  {tooth-forming)  cyst  growing  from  the  tooth-follicle, 


Fig.    13. — Chondroma   of  the  submaxillary   gland   which   had    been    slowly 
growing  for  forty-four  years  (Sutton). 


which  may  undergo  fibrous  change  and  may  become 
gradually  ossified.  Sometimes  several  hundred  teeth 
are  found  in  these  fibrous  masses.  (3)  From  the  papillcs 
as  small  tumors  composed  of  cementum  and  dentin. 
They  are  attached  only  to  the  roots  of  the  teeth,  and  are 
termed    radicular    tumors.      (4)    Composite    odontomata. 


lOO  TUMORS. 

These  growths  consist  of  tooth  tissue,  but  lack  tooth 
form.  They  are  apparently  composed  of  two  or  more 
germs  intermingled,  without  regard  to  the  normal  ar- 
rangement, and  are  irregular  masses  of  dentin,  enamel, 
and  other  tooth-formation. 

Odontomata  are  usually  seen  in  early  life  and  about 
puberty.  They  often  constitute  a  deformity,  and  fre- 
quently infection  and  local  inflammation  cause  them  to 
produce  distressing  symptoms. 

The  diagnosis  of  odontomata  is  not  alw^ays  clear. 
Tumors  of  the  bone  and  necrotic  diseases  are  usually 
softer  in  structure  than  tooth  tissue,  and  these  serve  to 
determine  their  character. 

Odontomata  are  practically  foreign  bodies  which  tend 

to   give   trouble   and    can   be    cured   only    by  removal. 

They  do  not  incline  to  malignancy,  but  the  continued 

irritation  may  establish  epithelioma  in  the  adjacent  soft 

parts.     The  treatment  is  removal  with  the  gouge  and 

chisel. 

ANGIOMA. 

This  form  of  neoplasm  is  composed  of  blood-vessels. 
They  constitute  the  simple  and  cavernous  nevi  and  the 
so-called  cirsoid  aneurysm  or  plexiform  angioma.  They 
are  usually  congenital,  although  some  first  begin  to  show 
in  the  first  few  weeks  of  life.  Not  infrequently  they 
gradually  become  fainter  and  smaller  until  they  disap- 
pear. Generally,  however,  they  extend  in  size,  and,  as 
complications  of  other  growths,  may  take  on  serious 
forms,  especially  in  malignant  tumors. 

The  nevus  is  the  most  common  form.  It  is  seen  chiefly 
about  the  face  and  neck,  sometimes  on  the  lip,  tongue, 
or  inner  cheek.  The  growth  is  often  a  bright  red,  berr}-- 
like  tumor,  at  times  prominent  above  the  surface  of  the 
tissues,  and  at  other  times  almost  flat.  The  so-called 
port-wine  mark,  is  sometimes  spread  over  half  the  face. 
These  growths  are  merely  enlarged  arterioles  and  ven- 
ules, sometimes  sacculated  and  intercommunicating. 

Diagnosis. — Usually  this  is  unmistakable  ;  the  spot 


ANGIOMA.  lOI 

is  congenital  (mother's  mark).  Its  color,  painlessness, 
disappearance  on  pressure,  with  prompt  return  and  slow 
growth,  all  render  the  diagnosis  a  simple  matter.  The 
cavernous  nevi  are  often  developed  later  in  life  and  are 
usually  sacculated  arterioles  containing  a  good  deal  of 
blood.  They  are  painless,  and  unless  some  complicating 
tumor  presents,  give  little  inconvenience  except  as  a 
blemish.  However,  such  growths  occupying  the  eye, 
the  antrum  of  Highmore,  or  the  liver  become  a  formida- 
ble menace. 

The  cirsoid  or  plexiform  aneurysm  is  an  exaggerated 
form  of  the  above,  always  consisting  of  dilated  arteries 
with  a  vigorous  pulsation.  At  times  it  is  painful. 
They  are  not  common,  but  are  seen  chiefly  on  the  fore- 
head or  scalp.  These  tumors  sometimes  get  as  large  as 
a  half  potato  and  even  larger. 

Treatment  of  Nevi.— Small  nevi  in  young  children 
may  disappear  ;  hence  it  is  not  well  to  hasten  treatment. 
If  they  are  growing,  however,  extirpation  is  most  appro- 
priate in  all  favorable  cases.  Those  on  the  tongue  may 
be  ligated  or  removed  with  thermocautery.  Electrolysis 
is  of  value  in  growths  too  extensive  to  justify  extirpa- 
tion. The  ligature  subcutaneously  is  employed  to  oblit- 
erate accessible  cavernous  nevi  unsuitable  for  extirpation. 

The  cirsoid  aneurysm  is  difficult  to  treat.  The  liga- 
ture, with  or  without  excision,  is  the  treatment  when 
any  is  applicable. 


CHAPTER    XIV. 
TUMORS  (Continued). 

CARCINOMATA. 

These  are  tumors  of  malignant  growth,  familiarly- 
known  as  cancer.  Keenest  interest  attaches  to  carcinoma 
wherever  situated,  because  of  its  wide-spread  distribution 
in  the  human  family,  and  the  great  dread  in  which  it  is 
held  on  account  of  its  usual  progressive  tendency  toward 
death.  Although  recent  surgical  progress  has  not  suc- 
ceeded in  determining  the  primary  cause  of  carcinoma, 
notwithstanding  the  patient  investigation  that  has  been 
unsuccessfully  conducted  to  prove  it  a  bacterial  disease, 
yet  experience  has  established  that  in  its  primary  mani- 
festations it  is  always  local,  and  if  promptly  and  thor- 
oughly excised,  will  not  recur  in  over  30  per  cent,  of 
cases. 

Carcinoma  histologically  is  an  epiblastic  epithelial  cell 
formation  of  embryonic  origin.  These  cells  are  without 
intercellular  matrix,  but  form  nests  of  cells,  under  a 
microscope  resembling  many  small  seeds  in  the  compart- 
ments of  a  bulb  or  burr  pod.  The  blood-vessels  ramify 
in  the  stroma  about  the  cell-nests.  The  blood-supply  of 
these  slow-growing  tumors  is  usually  scanty,  and  when 
cut  into,  they  bleed  little.  The  fibrous  tissue,  however, 
increases  and  compresses  the  vessels,  causing  later  ulcer- 
ation of  the  overlying  skin. 

Carcinomata  have  no  capsule,  but  infiltrate  the  sur- 
rounding tissue.  The  poison  of  carcinoma  is  conveyed 
by  the  lymphatic  vessels  to  neighboring  glands,  which 
in  turn  involve  those  of  the  next  current. 

Secondary  deposits,  called  metastases^  often  take  place 
in  the  stomach,  liver,  or  other  viscera  after  constitutional 
involvement  has  occurred.  This  metastasis  is  more  com- 
in2 


CARCINOMATA.  IO3 

monly  seen  in  the  scirrhous  carcinoma.  The  cancerous 
cachexia — the  muddy  complexion  and  sallow  skin^ 
indicates  constitutional  involvement  and  a  hopeless  con- 
dition. 

Practically  we  see  two  varieties  of  carcinoma  :  (i) 
Scirrhous  or  spheroid-celled,  with  a  form  termed  enceph- 
aloid^  rarely  seen  except  in  complication,  as  with  sarcoma. 
(2)  Epithelial  or  flat-celled. 

Scirrhous  carcinoma  arises  from  the  epithelium  of  the 
acinous  glands,  and  is  a  hard  growth,  with  little  vascu- 
larity, usually  involving  a  gland.  At  first  movable,  the 
growth  soon  infiltrates  the  gland  and  the  surrounding 
structures,  becoming  more  or  less  fixed.  The  fibrous 
tissue  in  the  growth  puckers  in  the  skin  and  produces  a 
nodular,  dimpled  appearance.  Usually  they  do  not  grow 
large.  Pain  is  early  felt,  at  first  as  a  darting  neuralgic 
flash,  but  later  on  assuming  more  the  character  of  a  con- 
stant ache.  This  is  doubtless  due  to  the  involvement 
of  nerve  terminals  in  the  growth.  When  cut  into,  such 
tumors  bleed  very  little,  but  show  a  hard,  gristly  tissue, 
which  at  times  holds  a  milky  fluid.  The  lymphatic 
glands  nearest  the  growth  usually  become  hardened, 
tender,  and  swollen  within  the  first  six  months. 

The  encephaloid  form  differs  in  being  of  rapid  growth, 
with  larger  and  more  numerous  blood-vessels,  and  a  soft, 
fluctuating  sensation  to  manipulation,  due  doubtless  to 
blood  in  the  growth.  Such  growths  are  rare,  seen  occa- 
sionally in  the  eye,  ovary,  and  testicle,  and  in  eveiything 
except  microscopic  appearance  resemble  the  sarcoma. 
Such  growths  sometimes  contain  cyst-like  cavities,  which 
hold  a  mucoid,  jelly-like  fluid  which  fills  out  the  alveola 
and  stroma  distinctly.  This  form  is  termed  colloid.  It 
is  seen  in  both  the  scirrhous  and  encephaloid  forms. 

Epithelial  carcinoma  originates,  as  the  name  indicates, 
from  skin  or  mucous  membrane  or  their  glands.  Usually 
they  begin  as  a  warty  growth,  often  at  the  mucocutaneous 
junction.  Frequently  this  growth  is  a  mere  fissure, 
which,  after  a  prolonged  period  of  inactivity,  has  taken 


I04  TUMORS. 

on  irritation  and  growth.  Usually  the  tumor  growth  in 
epithelioma  is  very  moderate,  and  even  after  months  of 
duration  still  remains  only  a  flat  ulcer  or  a  broad  wart. 

At  times,  however,  ulceration  marks  the  course  of  the 
growth,  and  without  elevation  of  the  parts  extensive 
destruction  of  superficial  tissues  goes  on.  The  growth 
of  epithelioma  is  usually  much  slower  than  that  of  other 
forms  of  cancer,  and  it  presents  less  tendency  to  recur 
when  extirpated.  Lymphatic  and  secondary  deposits 
are  often  delayed  a  long  time,  sometimes  several  years, 
although  there  is  no  assurance  that  such  growths  will 
not  at  any  time  present  evidences  of  cachectic  infection, 
and  be  rapidly  succeeded  by  exhaustion  and  death.  The 
pain  and  generally  depressing  symptoms  of  epithelioma 
are  also  less  prominent  than  in  other  forms. 

Epithelioma  of  the  larynx,  throat,  and  internal 
mucous  structures,  in  the  rectum  and  on  the  penis,  are 
more  frequently  attended  with  lymphatic  sympathy. 
The  usual  forms  are  superficial,  and  present  few  consti- 
tutional symptoms. 

The  so-called  rodent  idcer^  which  begins  as  a  small 
scale  on  the  nose  or  cheek,  continues  as  a  progressive 
superficial  ulceration  until  it  destroys  the  whole  face  to 
the  bone,  even  eating  up  the  eyelids.  It  is  attended 
with  little  pain  and  few  constitutional  symptoms  until  it 
destroys  the  superficial  bones  and  even  opens  large 
vessels. 

Diagnosis. — Epithelioma  of  the  face  cannot  well  be 
mistaken  for  any  other  lesion  if  the  history  be  carefully 
considered.  It  is  seen  rarely  before  the  fortieth  year, 
most  commonly  on  the  lower  lip,  most  frequent  in  the 
male.  It  is  often  referred  to  the  smoking  habit.  It  is 
also  seen  on  the  cheek  or  nose  in  either  sex  as  a  warty 
growth,  or  a  slow-growing  indolent  ulceration  or  fissure. 
It  exhibits  little  tumor  growth  or  lymphatic  enlargement 
in  early  stages,  with  little  pain  and  no  tendency  to  heal. 

Syphilis  is  to  be  eliminated  by  the  history,  age  of  the 
patient,  and  the  failure  of  specific  remedies  to  influence 


DIAGNOSIS    OF    CARCINOMA.  IO5 

the  growth.  Chancre  of  the  lip  has  not  rarely  been 
diagnosed  by  good  surgeons  as  epithelioma,  and  no 
doubtful  case  should  be  permitted  to  receive  judgment 
until  the  specific  treatment  is  tried.  The  symptoms  of 
chancre  of  the  lip  are  similar  to  those  of  chancre  else- 
where.    They  usually  get  well  without  treatment  in  a 


Fig.  14.  —Carcinoma  of  the  lower  lip  1  Sennj. 

couple  of  months,  and  are  attended  with  early  involve- 
ment of  the  lymphatics. 

Syphilitic  ulcerations  of  the  tongue  resemble  epithe- 
lioma somewhat,  but  they  are  usually  multiple,  painless, 
and  without  lymphatic  involvement,  and  generally  soon 
yield  to  constitutional  treatment. 

Tubercular  ulcerations  of  the  tongue  and  tonsils  are 
also  usually  multiple,  although  lupus  ulceration  often 
greatly  resembles  that  of  epithelioma,  but  is  generally 


I06  TUMORS. 

accompanied  with  tubercular  lesions  elsewhere  or  with  a 
history  in  itself  suspicious. 

In  the  rectum  and  uterus,  where  columnar,  rather 
than  the  squamous,  epithelium  prevails,  epithelioma 
presents  a  different  growth.  It  appears  rather  as  an 
infiltrating  mass  into  the  structures,  occasioning  deposits 
which  encroach  upon  or  perhaps  close  up  the  lumen,  as 
in  the  intestines  and  stomach.  This  form  is  called 
cylindric  or  columnar  epithelioma. 

The  diagnosis  of  carcinoma  is  made  upon  considera- 
tion of  the  age, — above  forty  usuall}', — the  presence  of 
a  painful  tumor,  which  is  often  fixed,  with  adherent 
skin,  later  ulceration,  lymphatic  involvement  in  the  first 
six  months,  with  progressive  growth,  pain,  loss  of  flesh, 
cachexia,  offensive  odor,  and  recurrence. 

Treatment.  —  Regarding  carcinoma  as,  for  some 
months  at  least,  a  local  disease,  with  a  distinctly  pro- 
gressive and  invariably  fatal  tendency,  there  can  be  but 
one  treatment  when  available,  and  that  is  wide  and 
complete  extirpation. 

When  lymphatic  involvement  (which  should  always 
be  sought  for  by  exploration  of  the  regions)  has  taken 
place,  the  glands  should  be  completely  removed.  When 
the  growth,  as  an  epithelioma,  is  seated  on  the  face,  free 
excision  is  early  deinanded.  When  the  tongue  is  in- 
volved, it  may  require  to  be  amputated.  Plastic  surgery 
will  often  cover  the  defect  left  by  free  operation,  but  no 
hesitancy  to  sacrifice  tissue  is  to  be  entertained  in  the 
presence  of  extensive  involvement. 

When  there  is  extensive  glandular  involvement  that 
is  not  susceptible  of  removal,  or  when  progressive 
cachexia  is  evident,  operative  measures  can  do  no  good 
except  for  palliation.  Caustics  are  not  to  be  employed 
when  the  knife  can  be  used.  It  should  constantly  be 
borne  in  mind  that  early  and  complete  extirpation  will 
cure  most  carcinomata,  and  tliat  only  early  diagno- 
sis, in  the  first  few  weeks,  and  prompt  and  efficient 
surgery  can  hope  to  rescue  the  sufferer. 


SUMMARY.  107 

SUMMARY. 

By  a  tumor  is  understood  a  neoplasm,  which  is  a 
growth  originating  from  preexisting  cells  of  embryonic 
life.  It  is  congenital,  and  resembles  normal  tissue,  though 
in  all  tumors,  even  benign,  some  abnormal  tissue  is 
present.  In  malignant  growths  the  embryonic  or  imma- 
ture cells  largely  predominate.  Homologous  tumors  re- 
semble surrounding  tissues  ;  heterologous  tumors  differ. 
Benign  tumors  are  painless,  slow  growing,  and  non-ad- 
herent. Tumors  are  classified  according  to  their  resem- 
blance to  normal  structures.  Papillomata  are  epithelial 
warts.  Adenomata  are  glandular.  Fibromata  are  hard. 
Lipomata  are  fatty.  Other  names  correspond  to  the 
tissues  involved.  Odontomata  are  tumors  of  the  tooth 
structures.  Nevi  are  blood  tumors  involving  small  ves- 
sels. 

Carcinomata  or  cancers  are  not  only  different  in  cells, 
but  also  in  arrangement  of  stroma  and  blood-vessels. 
They  are  without  capsule,  and  soon  produce  constitu- 
tional symptoms.  Scirrhous  and  epithelial  define  them- 
selves. Carcinomata  are  seen  in  middle  and  late  life, 
and  while  at  first  local,  after  a  few  months  become 
insusceptible  of  complete  removal.  Glandular  involve- 
ment and  the  yellow  cachexia  indicate  constitutional 
infection.     Treatment  is  early  extirpation. 


CHAPTER   XV. 
TUMORS  (Concluded). 

SARCOMA. 

A  sarcoma  or  "flesh"  tumor  is  the  most  primitive 
or  embryonic  of  all  growths  arising  from  the  mesoblast 
matrix.  The  center  of  these  growths  shows  the  embryonic 
nature  of  the  cells  less  than  the  outer  or  peripheral  por- 
tions, due  to  the  tendency  to  organize  as  the  growth  pro- 
gresses. Unlike  the  carcinomata,  these  tumors  have  little 
stroma,  and  the  blood-vessels  ramify  between  these  cells, 
often  seeming  to  have  no  walls  but  the  cells  themselves. 
Thus  can  be  appreciated  the  high  vascularity  of  the 
growth.  These  tumors  usually  grow  much  more  rapidly 
than  the  carcinomata,  except  the  encephaloid  variety, 
which  they  closely  resemble  in  clinical  history  and  ap- 
pearance. Lymphatic  involvement  is  very  infrequent, 
and  secondary  deposits  are  not  the  rule  in  these  growths, 
although  the  transportation  by  the  blood  of  fragments  of 
growth  to  other  situations  often  results  in  similar  neo- 
plasms. Sarcomata,  however,  grow  by  the  infiltration 
method,  and  tend  to  recur  locally  even  more  than  carci- 
nomata. Moreover,  they  are  more  difficult  to  eradicate. 
Sarcoma  is  found  in  every  tissue  from  the  eye  and  the 
brain  to  the  shaft  of  bone,  growing  with  an  irregular  pace, 
but  usually  extending  over  a  few  months  in  any  situation. 
The  cause  which  sets  to  growth  the  quiescent  embryonic 
cell  is  often  a  blow  or  injury  of  some  kind  upon  the  part. 
Three  forms  of  sarcoma  are  generally  recognized  : 
I.  Round-celled. — This  is  the  most  rapidly  growing 
and  malignant  form,  sometimes  attaining  a  great  size. 
The  tissue  of  this  growth  is  so  markedly  like  ordinary 
granulation    tissue  that    the    microscopist    may  be  de- 

108 


MYELOID    OR    GIANT-CELLED    SARCOMA. 


109 


ceived  if  only  limited  portions  of  the  tumor  are  sub- 
mitted. 

In  the  lymphosarcoma^  a  variety  of  the  round-celled 
sarcoma,  the  cells  resemble  the  tissue  of  the  lymphatic 
glands.  The  situation  and  conformation  of  these  tumors 
indicate  nomenclature  as  to  varieties,  but  such  classifica- 
tion is  of  no  pathologic  significance. 

2.  Spindle-celled  sarcoma  is  so  named  from  the 
shape  of  the  cells  composing  it.  It  is  less  vascular,  slower 
of  growth,  and  less  malignant  than  the  foregoing  variety. 


Fig.    15. — Cells  from  a  spindle-celled  sarcoma  of  the  neck  of  the  uterus; 
some  of  the  cells  present  a  cross-striation  (Pernice). 


It  is  seen  chiefly  in  the  skin,  ovary,  testicle,  and  eye. 
This  form  of  sarcoma  is  usually  softer  and  less  tense 
than  the  round-celled. 

In  the  center  of  bones  there  are  often  found  sarcomata 
with  a  mixture  of  the  round-  and  spindle-cells,  called 
mixed-celled  sarcomata. 

3.  Myeloid  or  Giant-celled  Sarcoma. — This  tumor 
usually  springs  from  the  medulla  of  bones,  and  resem- 
bles the  tissue  of  young  bone.     These  growths  are  some- 


no 


TUMORS. 


times    subperiosteal,    and,     indeed,    are   at    times    seen 
elsewhere  in  the  tissues. 

Symptoms  and  Course. — Unlike  carcinoma,  this  form 
of  malignant  growth  is  more  frequent  in  the  growing 
period  of  life  and  in  early  maturity.  The  different  forms 
progress  differently.  The  round-celled,  seen  usually  in 
the  softer  structures,  grows  with  great  rapidity,  often  sur- 
rounded by  a  capsule.  Frequently  it  contains  cysts,  is 
the  cause  of  little  pain,  and  makes  in  the  early  stages  an 


Fig.  i6. — Sarcoma  of  the  skull  secondary  to  sarcoma  of  the  jaw  (Tiffany). 

inconsiderable  impression  on  the  health.  Later,  how- 
ever, a  cachexia  appears,  ulceration  sets  up  in  the  growth, 
and  sepsis  is  inaugurated.  The  growth  gradually  infil- 
trates outside  the  capsule,  blood-vessels  become  large, 
and  hemorrhage  into  the  tumor,  or  at  times  escaping  at 
the  point  of  ulceration,  may  become  a  prominent  feature. 
The  lymphatics  usually  show  no  sympathy  with  the 
growth.  In  the  giant-celled  form  in  the  bone  the  prog- 
ress is  often  slow,  and  a  long  time  may  elapse  before  the 
tumor  attracts  attention. 


CYSTS.  1 1 1 

Sarcoma  is  nearly  always  more  or  less  compound,  pre- 
senting features  of  the  adenoma,  the  fibroma,  the  chon- 
droma, or  some  of  the  other  growths  of  the  connective- 
tissue  type. 

The  diagnosis  is  made  by  the  history  ;  rapid  growth  ; 
early  ulceration  ;  evident  constitutional  involvement ; 
the  microscope,  in  the  absence  of  a  question  of  inflam- 
matory growth,  which  resembles  the  cell  growth  directly, 
will  settle  the  doubt.  From  carcinoma,  in  the  absence 
of  the  microscope,  the  distinction  usually  rests  on  the 
lymphatic  involvement  attending  carcinoma,  rapidity  of 
growth,  and  painlessness. 

Progrnosis. — The  tendency  of  sarcoma  to  recur  in  loco 
makes  the  prognosis  a  little  more  hopeful  where  amputa- 
tion can  early  remove  it.  But  operations  on  the  tonsils, 
testicle,  throat,  and  trunk  are  highly  unpromising.  The 
round-celled  variety  is  the  least  hopeful  of  all  forms. 
The  m}-eloid  offers  the  best  prospect. 

Treatment. — Amputation  far  above  the  growth  in 
soft  structure  and  above  the  joint  in  bone  involvement 
is  imperative.  Nothing  short  of  free  and  extensive 
removal  offers  any  hope.  Reoperation  in  recurrence,  as 
often  as  there  is  a  prospect  of  removing  all  the  diseased 
tissue,  is  to  be  approved,  although  the  hope  is  a  frail 
one.  Hypodermic  injections  of  the  toxins  of  erysipelas, 
prepared  ready,  for  use  by  several  reputable  firms,  have 
been  claimed  to  cure  some  inoperable  sarcomata,  but  the 
experience  of  most  surgeons  has  been  disappointing. 
Little  is  claimed  for  it  except  in  the  myeloid  varietv, 
and  even  here  it  has  justified  the  confidence  of  few  sur- 
geons. The  X-ray  therapy  for  recurrent  and  inoperable 
sarcoma  is  now  being  extensively  tried  and  seems  prom- 
ising. Most  sarcomata  grow  irregularly:  first  fast,  then 
slow,  but  the  usual  course  of  the  more  malignant  forms 
is  over  four  to  ten  months  from  development.  The 
myeloid  form  is  an  exception,  and  may  continue  for 
years. 


112  TUMORS. 

CYSTS. 

By  a  cyst  is  practically  understood  a  cavity,  either 
normal  or  newly  formed,  lined  with  a  distinct  wall  and 
having  fluid  or  semisolid  contents.  Some  cysts  may 
contain  other  cysts  within  them,  even  made  up  of  mate- 
rial different  from  the  mother  cyst.  Some  contain  the 
normal  secretion  of  the  structures  from  which  they  arise, 
and  others  a  new  exudate  due  to  inflammation  or  disease. 
We  describe  cysts  as  of  four  varieties  : 

1.  Those  in  Preexisting  Cavities  or  Spaces. — Of 
these  there  are  three  : 

(a)  Exudation  cysts,  which  are  due  to  oversecretion  in 
the  closed  cavities  that  they  involve,  as  in  the  bursse  of 
joints,  sheaths  of  tendons,  etc. 

(b)  Retention  cysts,  due  to  the  confining,  in  glands  or 
cavities,  the  secretion  that  should  normally  escape,  but 
is  prohibited  by  disease  or  obstruction  of  the  efferent 
channels.  The  cysts  may  naturally  consist  of  mucus, 
the  secretion  of  glands  either  with  or  without  distinct 
ducts.  For  instance,  sebaceous  cysts  are  due  to  the 
plugging-up  of  the  orifice  of  the  sweat-glands,  and 
are  seen  chiefly  on  the  scalp,  face,  and  shoulders  (see 
description). 

(c)  Mucous  cysts,  due  to  obstruction  and  dilatation  of 
mucus-secreting  glands  in  mucous  membranes,  as  ran- 
ula,  etc.,  which  see. 

(d)  Extravasation  cysts  or  hemorrhage  into  closed 
serous  cavities. 

2.  Neoplasms. — This  variety  is  the  cyst  in  self-made 
cavities.  These  cysts  usually  contain  mucus,  sometimes 
serum,  which  may  undergo  degeneration  and  perhaps 
infection.  They  are  due  usually  to  some  persistent  local 
irritation. 

There  is  also  a  form  of  new-made  cyst  containing 
blood,  and  due  to  the  extravasation  of  blood  into  the 
tissues,  where  it  becomes  encapsulated. 

3.  Congenital  Cysts. — These  arise  from  the  folding- 
in  of  the  early  embryonic  growth  of  some  small  portion 


CONGENITAL    CYSTS. 


113 


of  the  epiblastic  or  skin-producing  layer,  thus  permit- 
ting its  cells  to  go  on  to  form  normal  structures  in  the 
improper  situation.  Most  of  these  cysts  are  termed  der- 
moids^ and  usually  contain  skin  secretions,  as  hair  and 
sebaceous  materials,  but  at  times  bone  and  teeth  are  to 
be  found  in  the  cysts.     Dermoids  are  usually  found  in 


Fig.  17.— Branchial  cyst  (Gould). 

the  testicle  and  ovary,  but  sometimes  in  other  situations^ 
especially  the  eye. 

The  congenital  occlusion  of  cavities  which  should  be 
normally  open,  as  the  so-called  branchial  cysts  in  the 
neck  and  one  or  two  forms  of  hydrocele,  belong  to  this 
division. 


114  TUMORS. 

The  treatment  of  these  cysts,  as  well  as  the  dermoid, 
is  careful  dissection  and  extirpation.  The  diagnosis  is 
usually  not  made  in  dermoids  until  removal  or  incision. 

Parasitic  Cysts. — The  best  illustration  is  the  hydatid 
or  echinococcus.  These  cysts  are  usually  pale  bodies, 
resembling  a  bunch  of  grapes,  contained  in  a  larger  cyst, 
termed  the  mother  cyst.  Within  the  small  cyst  are  the 
echinococci,  called  microscopic  "scolices,"  each  hav- 
ing four  suckers  and  a  pair  of  booklets  with  which  to 
fasten  itself  to  the  cyst  structures.  These  booklets  are 
diagnostic  of  the  pathology  of  the  cyst,  and  with  the 
aid  of  the  microscope  can  be  seen  on  section  of  the 
cyst.  The  growth  of  these  daughter  cysts  sometimes 
causes  rupture  of  the  mother  cyst,  with  perliaps  fatal 
result,  depending  upon  the  situation.  Frequently  the 
small  cysts  undergo  calcification  and  cease  to  grow. 
Kchinococci  are  seen  chiefly  in  the  eye,  liver,  ovary, 
and  breast.     Extirpation  is  indicated  when   accessible. 

SUMMARY. 

Sarcomata  resemble  embryonic  tissue,  with  better 
developed  cells  in  the  outer  portions  ;  frequently  encap- 
sulated. They  have  little  stroma,  are  highly  vascular, 
grow  rapidly,  do  not  give  rise  to  much  pain,  have  no 
lymphatic  involvement,  rarely  have  secondary  deposits, 
but  infiltrate  surrounding  structures.  They  are  round- 
celled,  spindle-celled,  and  giant-celled,  the  latter  being 
the  least  malignant.  They  occur  earlier  in  life  than 
carcinomata,  recur  in  loco^  and  are  very  diflicult  to 
eradicate.  They  are  more  rapidly  destructive  than 
carcinomata,  and  more  likely  to  recur,  unless  prevented 
by  high  amputation. 

Cysts  are  cavities,  usually  newly  formed,  containing 
fluids.  Exudation  and  retention  cysts  are  very  similar. 
New  formed  cysts  usually  contain  mucus ;  sometimes 
they  are  malignant.  Congenital  cysts  are  seen  in  ova- 
ries, testicles,  and  in  connection  with  improperly  closed 
coneenital  tracts. 


CHAPTER   XVI. 
SYPHILIS. 

So  widely  spread  and  seen  in  such  a  variety  of  forms, 
syphilis  is  a  subject  of  great  interest  to  all  students,  and 
particularly  to  dentists.  Not  only  are  its  ravages  fre- 
quently misunderstood  and  neglected  by  the  patient, 
but  the  lesions  are  a  dangerous  menace  to  family  and 
friends,  as  well  as  to  the  fingers  of  the  oral  surgeon  who 
examines  the  mouth.  Thus  a  woman  who  has  innocently 
acquired  the  disease  in  the  mouth  may  infect,  if  careless, 
those  whom  she  may  kiss  or  who  may  have  occasion  to 
manipulate  the  neighborhood  of  the  lesion.  So  the 
instruments,  fingers,  and  dressings  of  the  dentist  con- 
taminated unsuspectedly  by  the  syphilitic  virus  from  a 
diseased  mouth  may  convey  the  poison. 

Syphilis  is  a  disease  of  the  blood,  of  venereal  origin, 
manifesting  itself,  however,  in  every  part  of  the  body. 
In  the  majority  of  cases  infection  arises  through  the  con- 
tact of  the  lesion  of  the  first  or  second  stage  with  an 
abrasion  upon  the  person  of  another,  although  it  is 
occasionally  transmitted  by  means  of  towels,  drinking- 
cups,  and  like  mediate  means. 

ACQUIRED  SYPHILIS. 

Acquired  syphilis  is  distinguished  from  inherited  syph- 
ilis by  such  markings  that  the  two  are  best  described 
under  different  headings. 

Acquired  syphilis  is  studied  in  four  stages  : 

1.  The  period  of  i)iocitIation  is  the  period  between  infec- 
tion and  the  first  manifestation. 

2.  Primary  stage  is  the  appearance  of  the  first  sore 
and  its  progress. 

115 


Il6  SYPHILIS. 

J.  Secondary  syphilis  is  the  expression  of  the  disease 
in  the  skin  and  soft  parts. 

/{..    Tertiary  stage  is  when  later  manifestations  are  seen. 

Although  the  immense  majority  of  cases  of  syphilis 
originate  upon  the  genitals,  the  characteristic  features 
are  the  same  wherever  the  lesion  is  located,  Bxtra-gen- 
ital  chancre  situated  on  the  face  is  of  chief  interest  to 
the  dentist. 

The  period  of  incubation,  the  stage  of  inoculation, 
usually  extends  from  fifteen  to  thirty  days  after  infection 
— commonly  about  three  weeks.  During  this  time  the 
patient  notices  nothing.  The  initial  lesion  is  always  a 
chancre. 

Primary  Stage. — The  sore,  or  chancre,  first  appears  as 
a  small  ulcer,  with  an  indurated  base  and  a  slight  swell- 
ing of  the  part  where  it  is  placed.  The  ulcer  enlarges 
until  it  is  perhaps  as  large  as  half  the  little  finger-nail, 
and  at  the  end  of  a  week  or  so  is  a  lump  of  swollen 
tissue  with  some  induration,  about  the  size  of  the  end 
of  the  little  finger.  The  sore  is  usually  painless  or 
nearly  so  ;  there  is  some  stiffness  in  the  lip,  if  this  be 
the  location  of  the  sore,  but  no  severe  smarting  or 
tenderness.  The  ulcer  is  covered  with  a  grayish  dis- 
charge, small  in  amount.  Usually  almost  invariably 
the  sore  is  single,  and  will  not  inoculate  the  adjoining 
skin  of  the  patient.  Two  chancres  are  rare  in  the  same 
patient,  and  where  they  occur,  they  are  the  result  of  a 
simultaneous  inoculation.  Enlargement  of  the  lym- 
phatics under  the  jaw,  upon  the  infected  side  first,  later 
upon  the  other,  is  to  be  expected  about  the  second  week. 
These  glands  are  almost  painless  and  do  not  suppurate. 
The  sore  may  get  better  in  a  few  weeks,  but  often 
remains  sluggish  a  long  time,  with  some  slight  spread 
of  the  ulceration,  if  untreated. 

Secondary  Syphilis. — The  secondary  symptoms  are  to 
be  looked  for  about  six  weeks  from  the  appearance  of 
the  initial  sore.  If  specific  treatment  has  been  employed, 
or  sometimes  in  vigorous  constitutions,  it  may  be  several 


SECONDARY    SYPHILIS. 


117 


months  before  the  secondary  manifestations  ;  in  rare 
instances  well-authorized  diagnosis  of  chancre  will  be 
followed  by  no  secondary  symptoms — at  least  none  are 
noticed. 

These  symptoms  are  usually  preceded  by  a  sense  of 
feverishness,  slight  temperature,  and  malaise.  Early 
an  eruption  appears,  consisting  of  rose-colored  spots 
without  elevation,  scattered  over  the  back,  breast,  inside 
thighs,  palms,  and  soles.  The  eruption  spreads  slowly, 
and  a  week  or  two  elapses  before  the  entire  body  is 
covered.     As  it  fades  it  leaves  a  brownish  or  copper- 


FlG.  18. —  Syphilitic  nodes  of  the  skull. 


colored  spot.  Other  eruptions  may  succeed  this  ;  in  the 
second  stage,  papular  and  even  ulcerating  forms  present. 
Usually  these  conditions  are  more  severe  than  the  patient 
will  neglect,  and  come  under  the  notice  of  the  physician 
rather  than  the  dentist.  During  this  stage  the  hair, 
not  only  of  the  head,  but  face,  eyebrows,  etc.,  often 
falls  out  in  considerable  quantities.  Mucous  patches 
occur  in  the  mouth,  on  the  tongue,  lips,  or  side  of  the 
cheek.  These  ulcers  vary  in  size,  and  often  are  multiple 
— three  or  four  in  number.  They  usually  appear  shortly 
after  the  eruption,  and  the  two  taken  with  the  history 
confirm  a  doubtful  diagnosis.    These  patches  are  capable 


ii8 


SYPHILIS. 


of  transmitting  syphilis  in  the  same  way  as  the  initial 
lesion,  though  not  so  readily,  and  are  to  be  cautiously 
manipulated.  The  blood  in  the  other  forms  of  the 
secondary  eruption  is  feebly  endowed  with  the  infecting 


Fig.  19. — Syphilitic  sequestrum  of  frontal  bone.     Gumma  over  each  clavicle. 


power,    but   after   a   short  specific  treatment   loses  the 
tendency. 

Immunity  from  syphilis  in  the  great  majority  of  cases 
arises  after  one  infection.  The  germ  has  not  been 
isolated,  but  it  is  believed  to  exist.  In  order  for  infec- 
tion to  occur,  a  break  in  the  skin  or  mucous  membrane 


TERTIARY    SYPHILIS.  1 19 

must  be  present  to  the  virus,   and   some   constitutions 
appear  to  be  insusceptible  to  infection. 

Tertiary  Syphilis — The  tertiary  manifestations  of 
syphilis  are  found  everywhere  in  the  body  and  are  of  all 
varieties;  eruption,  ulcerations  of  skin,  and  mucous 
membrane;  gummatous  deposits  in  any  tissue,  brain, 
or  other  vital  organ;  caries  and  necrosis  of  bone  in  any 
of  a  thousand  forms.  These  lesions  are  not  communic- 
able. They  may  appear  at  any  period  after  the  second- 
ary stage,  but  are  rarely  deferred  more  than  two  or  three 
years,  and  in  cases  that  have  received  proper  treatment 


Fig.  20. — Gumma  of  the  frontal  bone  (C.  A.  Porter's  case). 

are  not  seen  at  all.  The  tendency  of  tertiary  lesions  is 
to  destruction,  while  the  primary  and  secondary  disappear 
of  themselves.  Of  the  many  tertiary  lesions,  th.& giutima 
and  the  mucous  ulcerations  and  sypJiilitic  necrosis  in- 
terest the  dentist. 

The  giinimata  are  processes  of  softening  in  which  a 
small,  chronic,  abscess-like  collection  forms,  and  later 
ulcerates,  leaving  a  sluggish  sore  that  does  not  tend  to 
heal.  Such  conditions  have  been  referred  to  under 
Diseases  of  the  ]\Iouth.  Gummatous  deposits  also  form 
in  bones  or  even  in  the  brain.  Under  specific  treatment 
eummata  mav  often  be  absorbed. 


I20  SYPHILIS. 

Mucous  ulcerations  are  usually  the  result  of  broken- 
down  gummata,  and  are  seen  in  the  mouth  and  rectum. 

Syphilitic  gummata  of  the  brain  are  an  exception  to 
the  effect  of  the  iodids,  and  are  not  easily  absorbed. 
They  are  usually  followed  by  paralysis,  and  these  lesions 
are  at  times  very  painful,  causing  distressing  headaches. 
The  same  is  true  of  the  syphilis  of  the  bones.  In  osteo- 
myelitis there  is  frequently  no  pain  in  the  daytime,  but 
it  becomes  so  severe  at  night  as  to  require  the  use  of 
opiates.  Night-pains  are  also  frequently  seen  in  syphilis 
of  the  brain. 

Diagnosis. — The  diagnosis  of  acquired  syphilis  in 
most  of  its  forms  is  made  out  without  difficulty  if  the 
history  can  be  obtained,  and  in  the  first  and  second 
stages  the  physical  appearances  are  usually  unmistakable. 
In  any  of  its  forms  the  administration  of  the  specific 
treatment  will  confirm  the  diagnosis. 

The  prognosis  in  acquired  syphilis  is  usually 
favorable.  In  the  last  twenty-five  years  syphilis  in 
general  has  been  much  milder,  due,  perhaps,  to  a  gradual 
inoculation  of  the  human  family  by  inheritance. 

In  many  of  the  milder  types  of  syphilis  the  initial 
lesion  is  insignificant  in  appearance  and  may  escape 
observation  altogether.  Even  without  treatment  the 
secondary  symptoms  may  be  quite  mild  and  the  tertiary 
symptoms  never  appear.  Usually,  however,  unless 
treatment  is  instituted  early,  the  eruption  is  profuse, 
and  the  other  symptoms  follow  in  order.  When  proper 
treatment  is  early  begun  and  faithfully  continued,  as 
far  as  the  individual  is  concerned,  the  disease  is  usually 
regarded  as  overcome  in  two  years,  counting  from  the 
appearance  of  the  last  symptom,  although  the  power 
to  transmit  the  disease  to  offspring  may  persist  for 
years  later. 

Treatment. — The  local  treatment  of  the  initial  lesion 
rarely  requires  anything  more  than  frequent  washes, 
for  cleanliness'  sake,  with  what  is  known  as  the  black 
wash,  and  either  boric  acid  or  calomel  or  some   bland 


TREATMENT.  121 

powder  may  be  applied  afterward.  Excision  of  the 
chancre  is  never  of  any  use,  nor  is  routine  cauterization. 
Inflamed  and  phagedenic  sores  should  be  cauterized  if 
there  be  any  tendency  to  spread.  As  soon  as  the  char- 
acter of  the  sore  is  determined  to  be  syphilitic,  constitu- 
tional treatment  should  be  begun,  but  not  before,  lest 
the  patient  be  in  doubt  as  to  whether  or  not  he  has  had 
syphilis.  The  constitutional  treatment  of  secondary 
manifestations  is  best  conducted,  under  ordinary  circum- 
stances, with  the  protiodid  of  mercury,  this  being  the 
most  convenient,  although  any  of  the  forms  of  mercury 
may  be  used. 

As  far  as  the  practice  of  the  dentist  is  concerned,  the 
simplest  method  is  to  begin  with  administering  a  tablet 
containing  a  fourth  of  a  grain  of  protiodid  four  times 
a  day,  increasing  it  one  tablet  every  other  day  until  the 
gums  begin  to  be  a  little  bluish  and  tender ;  usually 
seven  or  eight  tablets  will  be  enough  to  accomplish 
this.  The  number  of  tablets  should  then  be  reduced 
one-half,  and  continued  until  all  symptoms  have  disap- 
peared. The  treatment  should  be  intermittently  re- 
sumed and  continued  for  a  year  or  two,  in  proportion 
to  the  severity  of  the  attack. 

In  the  later  stages  of  the  second  and  third  forms  the 
iodid  of  potassium  may  with  advantage  be  combined 
with  the  mercury.  A  saturated  solution  of  the  iodid 
in  distilled  water  may  be  started  at  five  drops,  and  this 
increased  a  drop  daily  until  the  point  of  tolerance  is 
reached,  which  is  recognized  by  the  coryza,  reddened 
face  and  nose,  and  the  eruption  that  characterizes  the 
first  stage  of  poisoning  by  iodid  of  potassium.  The 
drug  should  then  be  withdrawn,  the  patient  meanwhile 
being  closely  watched  to  see  if  any  new  symptoms  appear. 

In  tertiary  syphilis  it  seems  of  little  use  to  push  mer- 
cury, the  best  results  being  obtained  by  the  iodids. 
Some  tonic  or  bitter  is  acceptable,  combined  with  the 
iodids,  by  which  the  appetite  is  kept  up.  Tincture  of 
gentian,  sarsaparilla,  stillingia,  are  good  combinations. 


122  SYPHILIS. 


INHERITED  SYPHILIS. 


x\s  has  been  intimated  in  this  description,  the  power 
to  transmit  syphilis  to  the  offspring  is  limited  to  the 
active  stage  of  the  primary  and  secondary  periods,  and, 
practically  speaking,  any  person  who  has  passed  the 
fourth  year  since  the  primary  lesion  is  out  of  danger  of 
transmitting  the  disease  to  the  fetus  in  utero ;  indeed, 
one  who  has  reached  the  end  of  the  second  year  after 
careful  treatment  is  practically  safe.  It  is  well  to  advise 
that  marriage  should  not  be  entered  into  sooner  than  one 
year  from  the  last  manifestations  after  discontinuing 
treatment.  When  the  syphilitic  father,  by  virtue  of  his 
blood  infection  through  the  semen, — not  by  the  direct 
virus,  however, — infects  the  ovule  of  the  mother,  and 
the  syphilitic  child  results,  in  the  great  majority  of 
cases  the  mother,  if  not  previously  immune,  is  also 
infected,  and  presents  the  classic  symptoms  of  the  second 
stage  of  syphilis.  Even  if  this  pregnancy  terminate  by 
abortion,  the  mother  is  not  likely  to  escape  infection. 
If  the  father  be  free,  but  the  mother  be  suffering  from 
secondary  syphilis,  the  child  will  likewise  suffer,  whether 
this  infection  has  occurred  before  the  conception  or  after- 
ward during  uterine  gestation. 

Symptoms. — In  the  majority  of  cases  symptoms  of  the 
hereditary  syphilis  are  seen  in  the  first  three  months. 
The  child  is  very  often  born  dead,  and  abortion,  often 
several  times  in  succession,  is  very  common.  When 
the  child  is  born  alive,  it  may  at  first  appear  vigorous, 
but  commonly  it  is  withered  and  feeble,  with  hoarse- 
ness and  a  characteristic  snufiling  sound.  An  early, 
blister-like  eruption,  called  pemphigus^  appears  upon 
the  face  and  body  ;  later  mucous  patches,  disease  of  the 
eye,  etc. ,  are  present.  IVTost  of  these  children  die  early. 
Those  who  reach  the  sixth  to  the  tenth  year  show  sus- 
picious indications.  Faulty  hearing  and  often  blind- 
ness, with  other  evidences  of  diseased  organs  and  im- 
perfect development,  are  a  part  of  the  history. 


INHERITED    SYPHILIS. 


123 


These  lesions  are  not  inocnlable.  The  chief  interest 
to  the  dentist  lies  in  the  imperfect  development  of  the 
teeth  and  jaws,  with  attending  necrosis.  The  peculiar 
serrated  or  notched  tooth,  crescentic  excavation  on  the 
edges,  with  deformed,  peg-shaped  stumps  are  charac- 
teristic. 

Hereditary  syphilis  may  affect  any  organ  in  the  body, 
and  such  symptoms  are  of  highest  interest  from  a  diag- 
nostic standpoint.  The  subject  is  too  extensive  to  be 
dwelt  on  here.  Usually,  from  a  diagnostic  point,  the 
history  from  childhood,  with  the  presence  of  unexplained 
eye,  nose,  or  ear  troubles  or  some  nervous  peculiarities, 
notched  or  irregular  teeth,  will  make  a  clear  diagnosis. 


Fig.  21. — Hutchinson's  teeth  (Parker):  i.  The  central  upper  incisors  of 
a  lad,  aged  fifteen  years,  the  subject  of  inherited  syphilis.  The  teeth  are 
short,  convergent,  narrow  from  side  to  side  at  their  edges,  and  show  in  each 
a  vertical  notch.  2.  These  teeth  present  similar  characters.  The  notches, 
however,  are  less  deep,  while  the  narrowing  from  side  to  side  is  very  marked. 
3.  The  upper  incisors  of  a  girl  aged  seventeen  years.  There  is  a  wide  space 
between  the  central  ones,  and  both  these  teeth,  although  of  nearly  normal 
length,  are  narrow,  and  show  deep  vertical  notches.  As  is  usual,  the  lateral 
incisors  are  of  normal  size  and  form.  These  teeth  are  not  so  typical  as  those 
shown  in  i  and  2. 

The  treatment  of  hereditary  syphilis  in  the  infant  is 
by  inunction  with  the  mercurial  ointment.  In  the  older 
child  the  iodid  of  potassium,  usually  in  syrup,  with 
small  doses  of  the  bichlorid  of  mercury,  care  in  diet,  and 
exercise  constitute  the  course. 


124  SYPHILIS. 

SUMMARY. 

Syphilis  is  a  blood  disease  often  innocently  acquired  ; 
it  manifests  itself  in  nearly  every  organ  and  part  of  the 
body. 

Acquired  syphilis  has  an  incubation  period  of  from 
fifteen  to  thirty  days.  Then  the  primary  stage,  ushered 
in  by  the  chancre,  lasts  from  forty-two  to  sixty  days 
before  the  rose-rash  and  the  mucous  patches  begin  the 
second  stage.  The  manifestations  of  the  tertiary  stage 
are  often  delayed  a  year  or  two.  The  chancre  is  a  pain- 
less ulcer  with  involvement  of  adjacent  lymphatics  in 
about  two  weeks. 

Mucous  patches  are  seen  in  the  mouth  and  nose,  and 
may  even  destroy  the  palate  and  nasal  bones  if  neglected. 
Infection  is  derived  both  from  the  initial  lesion  and  the 
mucous  patches,  as  well  as  rarely  through  the  blood. 
The  tertiary  lesions  do  not  communicate  the  disease. 
These  lesions  are  seen  late  ;  they  include  bone  syphilis, 
gummata,  and  skin  lesions,  chiefly  ulceration.  In  the 
second  and  third  stages  the  hair  often  falls  out.  The 
treatment  in  the  primary  and  secondary  stages  consists 
chiefly  of  mercury  and  cleanliness,  with  careful  diet. 
Stimulants  must  be  avoided.  In  the  tertiary  stage  iodids 
are  advantageously  combined,  and  stimulants,  nourish- 
ment, and  exercise  are  highly  valuable.  Transmission 
to  offspring  is  possible  only  in  the  primary  and  secondary 
stages.  If  well  two  years,  there  is  little  risk.  Infection 
of  the  ovule  by  the  father  conveys  syphilis  to  the  mother 
through  the  fetal  circulation. 

Abortion  or  premature  birth  of  dead  child  is  very 
common.  Symptoms  of  inherited  syphilis  are  seen  in 
early  life.  Child  is  feeble,  has  eruption,  may  be  blind 
or  deaf,  exhibits  ulcers  and  imperfect  teeth.  They  often 
improve  or  regain  complete  health.  Treatment  by  mer- 
curial inunction  and  iodid  of  potassium. 


CHAPTER     XVII. 

TUBERCULOSIS  OF  THE  BONES,  SKIN,  AND  MUCOUS 
MEMBRANES. 

Tuberculous  Bone  Disease. — The  exceeding  fre- 
quency of  tuberculous  bone  disease  has  made  it  familiar 
in  some  of  its  manifestations  to  every  observer  in  life. 
To  the  laity  it  is  universally  known  as  bone  sa'ofula  or 
white  swelling. 

Tuberculosis  as  it  interests  the  dentist  is  manifested  in 
the  skin.^  in  the  lymphatic  glands^  in  the  mucous  me7n- 
brane^  and  in  the  bones.  Tuberculosis  of  the  lungs,  the 
most  common  prominent  manifestation,  is  not  difficult 
of  recognition  when  far  enough  advanced  to  address  itself 
to  the  dentist. 

The  germ^  as  we  have  seen,  is  the  bacillus  of  Koch. 
It  is  slow  in  growing,  and  offers  great  resistance  to  all 
germicides  ;  indeed,  it  is  almost  impossible  to  eradicate 
it  from  tissues  when  once  fully  ensconced.  In  an  affected 
area  the  germs  are  few  in  number  and  are  not  directly 
transmissible  by  hereditation,  although  the  "  tuberculous 
tendency"  is  distinctly  characteristic  in  families. 

Tuberculosis,  however,  is  feebly  contagious  by  infec- 
tion through  the  inhalation  of  the  germ  or  by  direct 
admission  into  the  blood.  The  young  are  far  more  sus- 
ceptible to  the  disease,  and  aside  from  that  form  known 
as  tuberculous  phthisis,  or  consumption  of  the  lungs, 
childhood  is  the  age  of  predilection.  Skin  tuberculosis, 
however,  is  more  frequently  seen  in  adult  life. 

Pathology. — The  disease  gets  its  name  from  the  form 
of  its  manifestation.  The  tiibercle  is  the  result  of  an 
irritation  of  tissue-cells  by  the  bacillus,  which  accumu- 
late, nature  making  an  effort  to  destroy  the  germ  by 
phagocytosis.     These   tubercles  consist  of  white  blood- 

125 


126    TUBERCULOSIS  OF  BONES,  SKIN,  AND  MUCOUS  MEMBRANES. 

corpuscles,  epithelial  and  the  so-called  giant-cells,  with 
a  stroma  and  an  enveloping  membrane.  They  appear  to 
the  naked  eye  as  small  white  nodules.  These  tubercles 
merge,  soften  in  the  center,  and  thus  form  a  diseased 
spot  sometimes  encapsulated,  sometimes  merely  sur- 
rounded by  the  limiting  wall  of  resisting  cells.  These 
latter  may  hold  progress  in  abeyance  until  nature  has 
surrounded  the  focus  with  a  capsule,  and  thus  render  it 
temporarily  harmless.  The  germs  in  the  encapsulated 
tubercle  perish  from  starvation,  and  the  contents  are  in 
rare  instances  absorbed.  In  other  instances  the  germs 
retain  their  vitality  until  some  favorable  opportunity 
permits  renewed  progress  in  the  focus. 

By  caseation  of  the  tubercle  is  meant  the  cheesy  soft- 
ening which  gradually  takes  place  in  the  slowly  grow- 
ing process,  producing  a  yellowish  mass,  characteristic 
of  the  destructive  tubercular  process.  Further  softening 
and  liquefaction  of  these  tubercular  masses  produce  a 
puriform  fluid,  which  in  many  instances  contains  no 
germs  of  suppuration,  and  from  which,  indeed,  the 
tubercle  bacilli  are  often  absent ;  or,  if  present,  dead. 
Such  collection  is  termed  a  cold  abscess^  and  presents 
none  of  the  symptoms  of  the  acute  inflammation.  In- 
fection of  such  collections  with  the  germ  of  suppuration, 
however,  promptly  produces  mixed  infection,  character- 
ized by  hectic  fever. 

When  a  favorable  course  is  taken  by  the  tubercle,  cica- 
trization of  the  cavity  goes  on  until  the  destroyed  struc- 
ture is  replaced  by  fibrous  tissue  and  the  damage  thus 
repaired.  These  processes  are  the  course  of  tuberculosis 
in  all  organs  and  structures  of  the  body.  When  the 
organ  attacked  is  a  vital  one,  as  the  lungs,  pleura,  peri- 
toneum, or  brain,  death  almost  always  results  unless 
promptly  treated  ;  and  at  the  best  the  prognosis  is  un- 
favorable. In  the  less  important  tissues,  as  bone,  skin, 
and  joints,  the  prognosis  is  much  more  favorable  and 
the  process  much  slower. 

As  dentists,  we  study  the  manifestations  of  tuberculo- 


DIAGNOSIS — TREATMENT.  I  2/ 

sis  in  the  skin,  mucous  membrane,  glands,  and  bone.  It 
is  particularly  in  bone  tuberculosis  that  the  various  steps 
of  the  pathology  are  best  studied. 

When  deposits  take  place  in  the  form  of  acute  mili- 
ary tuber cidosis^  treatment  gives  little  promise  and  the 
patient  is  soon  overwhelmed  by  the  general  infection. 

Two  forms  interest  us  : 

/.  Tubercular  periostitis^  seen  in  the  ribs  and  occa- 
sionally upon  the  surface  of  the  maxilla  and  other 
long  bones  as  small  surface  patches  of  necrosis,  with 
sinuses  and  local  ulcers. 

2.  Tubercular  osteomyelitis^  beginning  in  the  epiph- 
yses, first  as  a  deposit  of  the  germ,  soon  forming  a  tuber- 
cle nodule  which  softens,  extends,  and  perhaps  under- 
goes caseation,  possible  encapsulation,  or  cicatrization, 
but  usually  suppuration  and  abscess  formation,  with 
sinus.  Not  infrequently  a  spot  of  lessened  resistance  is 
furnished  by  an  injury,  and  here  the  germ  circulating  in 
the  blood  prospers  and  multiplies.  In  the  early  stages 
there  is  inflammation  causing,  when  in  the  neighbor- 
hood of  a  joint,  stiffness  and  pain  on  motion,  with  ten- 
derness, slight  elevation  of  temperature,  a  swelling  of 
the  joint,  often  fusiform  in  shape,  with  later  softening, 
fluctuation,  hectic,  ulceration. 

If  the  disease  is  in  the  head  of  the  inferior  maxilla, 
motion  of  the  jaw  will  be  limited  by  pain,  swelling,  and 
tenderness,  becoming  worse  at  night.  Similar  local 
symptoms  will  characterize  this  lesion  in  the  fixed  facial 
bones. 

Diagnosis  is  made  by  the  histor>'  of  the  patient,  together 
with  the  symptoms  noted.  When  fluctuation  or  sinuses 
appear,  the  case  is  plainly  bone  disease,  which  may  be 
either  one  of  the  foregoing  forms.  The  ordinan,'  methods 
of  differentiating  tuberculosis  and  syphilis  from  infective 
inflammation  are  to  be  employed. 

Treatment. — In  all  conditions  without  external  com- 
munication and  suppuration  constitutional  remedies, 
good  hygiene,  and  favorable  climatic  conditions  consti- 


128     TUBERCULOSIS  OF  BONES,  SKIN,  AND  MUCOUS  MEMBRANES. 

tute  the  treatment.  Even  small  collections  of  tubercu- 
lous caseation  and  cold  abscesses  are  better  left  undis- 
turbed until  the  skin  begins  to  thin.  Aspiration  of 
deep-seated  collections  is  often  beneficial ;  recollection  is 
usually  less,  and  repeated  aspiration  with  constructive 
measures  may  prove  curative.  When  joints  are  involved, 
fixation  and  rest  should  be  persisted  in  until  a  cure  is 
effected,  or  until  the  conditions  demand  operation. 

When  abscesses  form,  or  when  progressive  disease  of 
the  bone,  particularly  of  the  face,  resists  conservative 
measures,  removal  of  the  cause  is  to  be  undertaken.  This 
is  chiefly  accomplished  by  free  incision  and  removal  of 
all  diseased  bone  with  the  curet  and  chisel,  as  widely  as 
is  consistent  with  the  condition.  Vital  structures,  like 
the  spinal  column,  and  even  the  larger  joints,  are  better 
treated  by  rest  and  care,  after  removing  the  collections 
of  puriform  material.  The  opening  of  large  uninfected 
abscesses  is  always  dangerous,  as  hectic  will  surely  fol- 
low the  admission  of  germs,  and  possibly  a  general  in- 
fection be  set  up.  Careful  asepsis  and  dressings  must 
be  employed.  When  sinuses  indicate  dead  bone,  they 
should  be  freely  enlarged,  and  the  caseous  or  necrotic 
disease  thoroughly  removed  by  chisel  and  curet,  fol- 
lowed by  antiseptic  irrigation  and  gauze  packing  to 
the  bottom.  Pure  carbolic  acid  may  be  poured  into 
these  sinuses  if  alcohol  is  added  within  a  minute  after- 
ward to  neutralize  the  excess.  Weak  solutions  of  for- 
malin, ^  of  I  per  cent.,  appear  to  limit  suppuration  in 
these  sinuses. 

Tuberculosis  of  the  skin  is  termed  lupus.  This  is  a 
raised,  reddish-brown  break  in  the  skin,  usually  elon- 
gated and  with  irregular  outlines,  with  a  tendency  to 
ulceration.  This  ulcer  spreads  slowly,  although  imper- 
fect cicatrization  in  parts  may  be  observed.  The  ulcer 
is  rarely  deeper  than  the  skin,  for  the  most  part  painless, 
and  of  limited  extent  for  a  long  time ;  but  when  it 
assumes  a  phagedenic  or  malignant  form — "lupus  ex- 
edens" — it  destroys  both  bone  and  cartilage  as  it   ad- 


TUBERCULOSIS    OF    MUCOUS    MEMBRANE    OF    THE    MOUTH.       1 29 

vances.  The  whole  of  the  face  may  be  one  raw  ulcer 
extending  to  the  bones,  and  perhaps  destroying  them. 
Even  this  form  is  consistent  with  years  of  life,  and  such 
hideously  deformed  unfortunates  may  be  seen  in  hospi- 
tals and  on  the  streets  for  years  and  years. 

Treatment  of  lupus  is  not  so  satisfactory  as  would  be 
expected.  When  small  and  favorably  situated,  free  ex- 
tirpation is  recommended.  When  this  is  not  appropri- 
ate, curetment  and  cauterization  with  pure  carbolic  acid, 
followed  by  washing  with  alcohol,  appears  the  most 
satisfactory. 

Tuberculosis  of  mucous  membraue  of  the  mouth 
has  already  been  discussed. 

Tuberculous  lymphatic  glands  of  the  neck  are  of  in- 
terest to  the  dentist.  They  are  chiefly  seen  in  children, 
beginning  as  a  slow,  painless  enlargement,  sometimes 
single,  sometimes  multiple,  sometimes  hard  and  later 
softening,  breaking  down  and  discharging  through  the 
sinus. 

The  diagnosis  of  the  nature  of  the  condition  is  made 
by  the  scrofulous  appearance,  usually  blonde  complexion, 
and  the  history. 

We  exclude,  in  diagnosis,  the  so-called  Hodgkin's 
disease,  or  lymphadenoma,  in  which  most  of  the  lym- 
phatics of  the  body  are  successively  involved,  and  a 
pernicious  anemia  and  exhaustion  cause  death. 

Treatment — There  is  considerable  difference  of  opinion 
among  surgeons  as  to  the  treatment  of  this  condition. 
The  author  believes,  however,  that  so  long  as  the  glands 
are  single  or  few,  the  expectant  plan  should  be  followed. 
When  softening  and  breaking  down  or  sinus  and  dis- 
charge become  a  complication,  prompt  and  complete 
extirpation  is  demanded. 

Local  applications  of  stimulants  to  absorbent  glands, 
with  the  administration  of  iodid  of  iron  and  good  nour- 
ishment, the  withdrawal  of  all  cooked  sugar,  pastr}^,  and 
indigestible  articles  of  diet,  work  great  results,  aided  by 
the  resistance  of  nature. 
9 


130    TUBERCULOSIS  OF  BONES,  SKIN,  AND  MUCOUS  MEMBRANES. 

SUMMARY. 

By  tttberciilosis  of  bone  we  understand  a  softening 
effect  of  the  structures  invaded  by  the  bacilli,  with 
liquefaction  and  apparent  abscess  formation,  to  which 
admission  of  germs  of  suppuration  add  sepsis  and 
mixed  infection.  Bone-lesions  are  seen  as  tubercular 
periostitis,  slight  in  extent,  and  osteomyelitis,  which 
affects  first  the  epiphyses  and  occasionally  the  medulla, 
and  later  the  joints.  The  progress  of  the  disease  is  slow, 
and  in  strong  constitutions  may  be  arrested  by  nature. 
If  inflammation  occurs  in  joints,  pain,  tenderness,  and 
rigidity,  with  later  suppuration,  mark  the  course.  The 
treatment  of  these  conditions  is  rest,  fixation,  aspiration 
of  pus  collections,  if  necessary  evacuation  of  the  abscess 
under  antiseptic  precautions.  Sinuses  should  be  cleaned 
out  and  cauterized,  and  dead  bone  cureted  when  the 
abscess  opens  and  discharges. 

Tuberculosis  of  skin  and  mucous  me7nbrane  is  some- 
times extensive  and  severe,  and  as  such  is  troublesome 
to  manage.  Enlarged  lymphatic  glands  usually  respond 
to  constitutional  treatment,  but  the  progress  is  slow. 


CHAPTER    XVIII. 
DISEASES  OF  THE  BONES  AND  LYMPHATICS. 

DJSEASES  OF  THE  BONES. 

If  the  student  constantly  keeps  in  mind  the  idea  that 
the  processes  of  inflammation  are  the  same  in  all  struc- 
tures, hard  and  soft,  and  are  pathologic  when  the  germs 
overcome  the  resistance  of  nature,  it  will  be  easy  to 
understand  that  inflammation,  ulceration,  sloughing,  and 
gangrene  have  their  counterpart  in  all  the  various  struc- 
tures of  the  body.  Hence  we  have  acute  and  'chronic^ 
as  well  as  specific  inflammations  of  bone,  which  produce 
effects  in  proportion  to  situation  and  severity,  and  which 
are  easily  understood. 

Periostitis. — By  the  term  periostitis  is  meant  disease 
of  the  outer  or  periosteal  covering  of  the  bone.  So  uni- 
formly, however,  does  this  inflammation  extend  into  the 
bone  that  the  term  osteoperiostitis  is  more  appropriate. 
Almost  always  this  inflammation  is  suppurative,  and 
unless  early  evacuation  of  the  pus  is  obtained,  consider- 
able destruction  of  the  bone,  as  well  as  severe  constitu- 
tional symptoms,  are  set  up. 

A  familiar  example  of  acute  osteoperiostitis  is  the  bone 
felon  of  the  phalanges.  Less  frequently  such  infections 
are  seen  in  other  situations  upon  the  legs,  and  rarelv  in 
the  bones  of  the  arm  and  cranium.  Such  lesions  are 
the  result  of  infection,  commonly  from  a  puncture  or 
even  a  diseased  hair-follicle,  a  bruise  producing  a  spot 
of  lessened  resistance  which  attracts  and  nourishes  some 
germ  floating  in  the  blood. 

Symptoms. — Tenderness,  and  in  a  day  or  so  pain  ; 
throbbing,  often  very  severe  at  night  ;  swelling  over  the 


132  DISEASES    OF    THE    BONES. 

part,  and  redness.  Dependency  of  the  part  aggravates 
the  suflfering.  If  the  trouble  is  in  a  large  bone,  elevated 
temperature  and  constitutional  symptoms  are  usually 
set  up. 

Diagnosis  is  usually  easy. 

Treatment  consists  in  free  incision  through  the  perios- 
teum, with  irrigation  and  drainage.  If  diseased  bone  is 
present,  it  should  be  removed  with  the  curet. 

Chronic  tubercular  and  syphilitic  lesions  of  this  char- 
acter belong  to  a  class  to  be  studied  a  little  later. 

Osteomyelitis  is  an  inflammation  of  the  shaft  and 
marrow,  or  medulla,  of  the  bone.  Usually  this  condi- 
tion begins  from  within  the  medulla,  but  occasionally 
the  germs  of  periostitis  spread  through  the  bone  by 
direct  invasion.  The  cause  is  usually  a  wound,  as  a 
fracture,  communicating  with  the  air  ;  a  bullet  wound  is 
a  common  source.  Osteomyelitis  is  at  times  seen  to  set 
up  in  the  course  of  a  low  or  infective  fever,  like  typhoid 
or  scarlet.  The  first  form  is  termed  septic^  and  the  latter 
infective  osteomyelitis.  In  the  former  the  germ  of  sup- 
puration gains  admission  from  without  ;  in  the  latter  the 
special  germ,  floating  in  the  blood,  finds  a  favorable  spot 
and  multiplies.  In  the  latter  form  the  infection  is  usually 
in  the  epiphyseal  ends  of  the  bone. 

The  course  of  an  inflammation  of  the  bone  structure  is 
to  fill  the  vessels  with  blood,  and  because  of  their  un- 
yielding walls,  to  produce  such  congestion,  stagnation, 
and  infiltration  with  blood,  and  perhaps  pus,  that  the 
bone  dies  in  a  considerable  portion,  making  a  slough  or 
gangrene  of  the  bone,  termed  necrosis.  The  shaft  of 
the  bone  in  its  central  portion  usually  becomes  this 
slough,  and  around  it  and  through  openings,  termed 
cloaca.^  in  those  portions  that  do  not  die  is  poured  out  the 
pus  and  various  inflammatory  exudates.  These  exudates 
are  discharged  through  sinuses  in  the  skin  and  soft  parts. 
Organization  of  the  less  virulent  exudates  forms  a  shell 
of  bone  which  surrounds  the  dead  slough  ;  this  slough 
later    becomes    loosened  from    the    surrounding    shell. 


OSTEOMYELITIS. 


133 


This  central  slough  or  dead  bone  is  termed  sequestrum ; 
the  surrounding  shell  the  invohicrum. 

The  symptoms  of  acute  osteomyelitis  are  usually 
severe,  and  consist  in  local  pain,  fever,  early  delirium, 
swelling  of  the  part,  and  a  general  condition  resembling 


Fig.  22. — Acute  osteomyelitis  of  the  tibia  (Nichols). 

acute  typhoid  fever.  Pus  soon  forms,  and  unless  deeply 
seated,  redness  and  fluctuation  indicate  it.  In  children 
the  symptoms  often  resemble  rheumatism.  A  high 
grade  of  septic  infection  often  arises,  and  death  may  take 
place  within  a  week.     In  perhaps  50  per  cent,  of  cases 


134  DISEASES    OF    THE    BONES. 

the  progress  is  less  rapid,  but  in  all  there  is  considerable 
destruction  of  bone  in  a  short  time.  If  a  joint  becomes 
involved  and  suppurates,  it  will  almost  surely  be  de- 
stroyed. When  the  trouble  is  the  result  of  infection 
through  an  open  wound,  there  is  usually  an  opportunity 
for  drainage,  and  the  escape  of  pus  renders  the  progress 
less  rapid  and  destructive. 

The  diagnosis  of  osteomyelitis,  when  an  open  wound 
is  present,  is  usually  not  difficult,  though  even  then 
enough  stress  is  not  always  put  on  the  character  of  the 
infection  in  the  bone  structures.  When,  however,  the 
disease  is  of  the  infective  form,  it  may  be  mistaken  for 
rheumatism  and  typhoid  fever.  The  local  symptoms, 
especially  the  localized  redness  and  pain,  with  quick 
pulse  and  temperature,  will  aid  in  settling  the  matter. 
When  the  destructive  character  of  the  inflammation  is 
borne  in  mind,  it  is  easy  to  see  how  important  early 
diagnosis  and  treatment  must  be.  Even  when  death 
does  not  take  place  soon,  severe  osteomyelitis,  notwith- 
standing it  is  most  carefully  treated,  will  usually  leave 
a  life-long  cripple. 

Treatment. — Only  during  a  stage  of  diagnosis  are  the 
usual  poultices  and  antiseptic  applications  permissible. 
As  soon  as  localized  inflammation  of  bone  can  be  made 
out,  chloroform  and  free  incision  through  all  diseased 
tissue, — and  frequently  into  the  medulla  if  indicated, — 
irrigation,  and  drainage  are  demanded.  If  joints  are 
involved,  they  must  be  opened  freely,  irrigated  with  anti- 
septics, and  drained.  As  a  rule,  it  is  better  not  to  disturb 
the  bone  too  much  after  free  drainage,  as  it  will  separate 
itself  better  than  the  surgeon  can  do  it  at  this  stage. 

Osteomyelitis  beginning  in  the  epiphysis, — "acute 
epiphysitis," — when  promptly  recognized,  gives  a  good 
prognosis  as  to  recovery  of  useful  joint,  but  after  sup- 
puration involves  the  joint  amputation  is  likely  to  be 
required. 

Necrosis. — By  this  term,  as  we  have  already  seen,  is 
meant  death  of  the  bone  en  masse.     This  mass  may  be 


SYMPTOMS TREATMENT.  1 35 

the  body  of  the  bone-shaft,  or  it  may  be  a  slab  of  that 
body,  just  as  gangrene  may  involve  the  whole  leg,  or 
only  a  slough  of  one  side  or  a  portion  of  it.  When  this 
slough  is  the  shaft,  its  inner  part  undergoes  destruction, 
the  discharges  escape  through  openings  in  the  shaft 
termed  cloaca^  the  dead  portion  or  sequestrum  sepa- 
rates from  the  outer  part,  which  is  increased  in  density 
by  organization  of  inflammatory  materials  thrown  out 
by  the  periosteum.  This  outer  covering  surrounding 
the  sequestrum  is  the  involucrit-m.  It  is  perhaps  full  of 
cloaca,  but  still  remains  the  support  of  the  limb.  If  the 
sequestrum,  however,  is  a  surface  slab,  there  is  no  invo- 
lucrum.  So  long  as  the  dead  fragment  remains,  either 
within  the  involucrum  or  upon  its  external  surface, 
suppuration  and  sinuses  will  persist. 

Symptoms  of  necrosis  are  the  sinuses  and  discharge, 
and  through  a  sinus  a  probe  will  feel  rough  dead  bone, 
often  moveable.  Sometimes  fragments  will  be  dis- 
charged, and  in  this  way  a  spontaneous  cure  may  be 
effected. 

Treatment. — Usually  it  is  best  to  let  dead  bone  sepa- 
rate itself  from  the  living  before  attempting  to  extract  it. 
When,  however,  the  dead  bone,  though  loose,  is  im- 
prisoned in  the  involucrum,  or  held  to  the  surface  of  the 
shaft  by  small  adhesive  points,  incision  and  removal, 
with  enlargement  of  the  cloaca  in  the  involucrum  if 
necessary,  are  indicated.  After  removal,  irrigation  with 
drainage  should  be  made.  Granulation  and  healing  of 
the  sinus  will  usually  result. 

Osteomyelitis  may  easily  attack  either  jaw,  the  infec- 
tion arising  from  a  diseased  tooth,  originating  usually  as 
a  periostitis.  Such  conditions  should  be  promptly  and 
freely  drained.  Sometimes  total  necrosis  of  the  jaw  is 
seen,  but  extensive  disease,  aside  from  specific,  is  rare. 

Chronic  osteomyelitis,  except  occurring  in  the  course 
of  syphilis  or  tuberculosis,  is  rare,  and  usually  pursues 
a  subacute  course,  with  tenderness,  attacks  of  pain, 
and  periods  of  intermission.     Finally,    an    abscess  dis- 


136  DISEASES    OF    THE    LYMPHATICS. 

closes  the  seat  of  necrosis,  and  later  a  sequestrum  may 
be  removed. 

DISEASES  OF    THE    LYMPHATICS. 

Note  is  made  in  the  discussion  of  blood  poisons  of  the 
extent  of  such  foci  along  the  lymphatics,  with  redness 
and  tenderness,  termed  lymphangitis.  Such  a  condi- 
tion may  be  septic  or  tubercular.  Mild  inflammations 
of  this  character  subside  without  treatment;  severer 
forms  require  poultices,  hot  packs,  and  often  such  con- 
stitutional remedies  as  purgatives  and  sedatives.  Sup- 
puration, as  has  been  said  under  infected  wounds,  may 
often  develop  (see  Septicemia).  In  the  milder  forms  of 
lymphangitis  compresses  saturated  with  alcohol  seem  to 
exert  a  specific  influence.  Tubercular  lymphangitis  is 
chronic,  and  is  due  to  the  transportation  of  the  bacilli  from 
one  gland  to  another.     Extirpation  is  the  only  remedy. 

The  treatment  of  tubercular  adenitis  is  elsewhere 
discussed. 

Obstruction  of  the  lymphatics  by  a  chronic  inflam- 
mation in  some  instances  occasions  a  swelling  of  the 
part,  a  brawny  thickening  of  the  skin,  and  an  edematous 
pitting,  often  with  aching  pain  and  some  temperature. 
This  condition  is  known  as  lymphede7na.  It  is  most 
commonly  seen  after  injuries  to  glands  and  ducts  from 
accident  or  surgical  operations.  Such  conditions  may 
exist  for  years,  and  often  without  much  constitutional 
distress.  In  the  acute  form  infection,  suppuration,  and 
death  may  at  times  be  the  course. 

The  presence  in  the  lymphatics  of  the  parasite  termed 
filaiHa  sanguinis  hominis  produces  that  painless  form  of 
lymphangitis  called  elephantiasis. 

The  treatment  of  chronic  lymphedema  is  support  and 
elevation  of  the  part.  Little  is  to  be  hoped  for  beyond 
contributing  to  the  comfort  of  the  patient. 

For  elephantiasis  removal  of  the  nerve-supply  by  ex- 
cision has  been  tried  with  little  benefit.  Amputation  is 
to  be  recommended  in  suitable  cases. 


LYMPHADENOMA. 


137 


lyymphadenoma  indicates  a  condition  of  multiple 
glandular  hypertrophy  without  tendency  to  suppuration. 
In  the  true  form  there  is  found  a  condition  of  leiiko- 
cythemia^  or  great  increase  in  the  white  corpuscles.  It 
is  rather  an  affection  for  internal  medication  than  for 
surgery. 

Malignafit   lymphoma^    or    Hodgkin's    disease,    is    a 


Fig.  23. — Malignant  lymphoma  ;   Hodgkin's  disease  (Nancrede). 


swelling  of  one  or  more  glands,  perhaps  first  in  the 
axilla,  groin,  or  neck.  It  is  painless,  and  at  first  without 
depression  of  the  general  health.  Other  glands  become 
involved,  and  in  the  course  of  a  year  nearly  all  the 
glands  of  the  body  are  affected.  Weakness,  enfeebled 
circulation,  and  death  are  the  course.  It  is  probably  a 
more  virulent  form  of  lymphadenoma. 

The  disease  is  chiefly  observed  in  young  adults,  al- 


138  DISEASES    OF    THE    LYMPHATICS. 

though  it  is  seen  in  children.  The  diagnosis  is  made  by 
the  progressive  involvement.  The  cause  is  unknown. 
It  pursues  an  uninterrupted  course  to  the  grave. 

SUMMARY. 

Chronic  disease  of  the  bone  is  due  to  tuberculosis  or 
syphilis,  and  occasionally  to  chronic  inflammation,  termed 
osteomyelitis.  This  last  is  due  to  infection,  and  in  the 
acute  stage  is  very  disastrous.  The  dead  bone,  or  se- 
questrum, that  results  acts  as  a  foreign  body  and  should 
be  removed  as  soon  as  it  loosens. 

Necrosis  of  the  bones  of  the  jaw  may  produce  extensive 
sequestra,  and  is  due  to  any  of  these  causes.  The  treat- 
ment is  removal  by  curetment  or  bone  forceps  after  the 
dead  bone  has  separated  from  the  living,  or  before  if  it 
is  causing:  much  constitutional  disturbance. 


CHAPTER   XIX. 

DISEASES  AND  ULCERATIONS   OF   THE   GUMS  AND 

MOUTH. 

Gingivitis. — Gingivitis,  or  inflammation  of  the  gums, 
is  due  to  an  infection  after  irritation,  either  from  food  or 
minerals,  like  lead  and  mercury,  or  to  the  presence  of 
tartar  on  the  teeth. 

Symptoms  are  tenderness  and  swelling  of  the  gums, 
bleeding  on  touch,  offensive,  laden  breath,  and  increased 
salivation.  Occasionally  ulcerated  spots  appear.  De- 
posits of  tartar,  often  quite  large  and  deeply  burrowing, 
will  usually  be  seen.  When  the  inflammation  is  due  to 
mercury,  the  characteristic  blue  on  the  gum-line  of  the 
front  teeth,  with  fetid  breath,  loosened  teeth,  and  the 
increased  flow  of  saliva,  together  with  the  history,  make 
the  diagnosis  easy.      Scurvy  is  treated  of  elsewhere. 

Treatment. — The  removal  of  the  tartar,  followed  by  a 
simple  mouth-wash,  will  usually  effect  the  cure  when 
this  is  the  cause. 

In  mercurial  gingivitis  the  recognition  of  the  cause, 
free  elimination  by  purgation,  and  the  internal  adminis- 
tration of  chlorate  of  potassium  in  3-grain  doses  three 
times  daily.  A  mouth-wash  of  equal  parts  of  peroxid 
of  hydrogen  and  listerin  answers  admirably.  The  sim- 
plest diet  only  must  be  allowed,  and  nothing  hot  must 
be  taken  in  the  mouth.  If  considerable  ulceration 
follows  the  salivation,  cauterization  with  crystals  of 
silver  nitrate  is  useful. 

In  lead-poisoning  the  gargles  are  usually  sufficient; 
iodid  of  potassium  in  solutions  of  3  to  5  grains  three 
times  dailv  is  of  service  in  this  form  of  ging^ivitis. 

Ulcers. — Ulcers   in    the   mucous    membrane    of   the 

139 


140    DISEASES    AND    ULCERATIONS    OF    GUMS    AND    MOUTH. 

mouth  are  usually  chronic,  and  due  to  local  traumatism, 
tuberculosis,  or  malignancy. 

The  accidental  or  intentional  ingestion  of  caustics 
may  leave  ulcers  and  cicatricial  tissues.  Commonly  such 
ulcers  heal  unless  constantly  disturbed  by  the  movement 
of  the  jaws,  and  may  be  so  situated  that  the  cicatrix  will 
endanger  the  freedom  of  the  articulation.  The  diagno- 
sis of  such  lesions  is  made  by  the  history.  The  treat- 
ment consists  in  antiseptic  gargles  and  occasionally  a 
stimulating  caustic  application. 

Syphilitic  ulcerations  are  seen  on  the  tonsils,  the  side 
and  surface  of  the  tongue,  and  on  the  walls  of  the 
cheek.  They  are  usually  gummata,  and  belong  to  the 
later  stages,  although  mucous  patches  are  often  seen. 
Usually  they  are  multiple.  Commonly  these  ulcerations 
are  slow  growing  and  painless,  but  at  times  the  ulcer  is 
very  destructive,  eating  away  the  soft  structures  and 
even  the  palate  bone,  and  invading  and  destroying  the 
nose  in  spite  of  any  treatment. 

Diagnosis  of  this  lesion  is  usually  made  from  the  his- 
tory of  the  case  as  well  as  the  existence  of  other  syph- 
ilitic manifestations  elsewhere.  These  are  multiple 
ulcers,  painless  and  slow  growing,  attended  by  offensive 
breath,  usually  swollen  tissues,  and  commonly  improve- 
ment under  mercury  and  the  iodids,  with  the  history 
and  the  other  lesions  if  syphilitic. 

The  treatment  here  is  that  of  syphilis:  cleanliness, 
gargles  of  listerin,  borax,  myrrh,  with  specific  remedies 
soon  produce  a  return  to  the  normal. 

Tuberculai'-  ulcerations^  or  lupus,  are  usually  single, 
painless,  and  without  offensive  odor.  Unlike  syphilitic 
ulcers,  the  tissues  do  not  swell,  but  are  nearly  level  with 
the  healthy  structures.  The  reddened,  granular  appear- 
ance of  lupus  has  been  noted.  Other  indications  of 
tuberculosis — enlarged  glands,  with  constitutional  diath- 
esis, and  family  history — aid  in  the  diagnosis.  This 
form  does  not,  of  course,  show  improvement  from  mer- 
cury.    The  treatment  is  clearly  the  gargling  and  con- 


EPITHELIOMA — SCURVY.  I4I 

stitutional  tonics  elsewhere  discussed;  extirpation  may 
at  times  be  appropriate. 

Bpithelioma  is  chiefly  seen  on  the  tongue,  if  within 
the  buccal  cavity,  although  occasionally  on  the  inner 
wall  of  the  cheeks.  When  located  on  the  tongue, 
usually  the  tip  or  the  lateral  margins  are  the  seats. 

A  history  of  smoking  is  very  common.  Heredity 
seems  to  have  little  influence.  The  growth  is  more  or 
less  elevated,  with  ulcerated  surface  and  indurated  base. 
The  discharge  is  offensive,  and  the  ulcer  is  painful, 
sometimes  agonizing.  In  the  later  stages  phonation  is 
much  impaired. 

Diagnosis. — Chancre  and  gumma  are  seen  in  younger 
persons,  and  are  attended  with  early  lymphatic  involve- 
ment. Care  should  always  be  taken  in  doubtful  cases  to 
determine  diagnosis  by  mercury.  The  microscope  will 
aid  in  deciding  against  tuberculosis. 

Treatment  of  epithelioma  is  extirpation  of  the  organ, 
preferably  by  Kocher's  method,  unless  the  case  is  seen 
very  early.     Recurrence  in  the  stump  is  the  rule. 

Scurvy. — Although  this  is  a  condition  not  often  met 
with  in  inland  districts,  and  rarely,  if  at  all,  in  civil 
life,  it  presents  symptoms  of  occasional  interest.  The 
pathology  is  not  clear.  Bacterial  origin  has  not  been 
proved  to  account  for  it,  although  some  sort  of  parasite 
is  believed  to  be  a  feature  in  the  etiology.  The  disease 
is  essentially  one  of  profound  denutrition,  seen  in  badly 
nourished  sailors  and  soldiers  living  in  overcrowded 
quarters.  Bad  food  and  an  insufficient  supply,  espe- 
cially of  vegetables  and  acids,  are  the  exciting  causes. 
Among  shipwrecked  sailors,  and  on  badly  ventilated 
ships  and  in  prisons,  where  vegetable  food  is  unobtain- 
able, scurvy  exists  as  an  epidemic  or  complicates  every 
other  ailment. 

Symptoms. — The  premonitory  indications  are  those 
of  prostration  and  general  weakness.  The  complexion 
of  the  patient  is  yellow,  the  appetite  fails,  and  the  di- 
gestion   becomes    impaired.      Then    the    gums    swell, 


142    DISEASES    AND    ULCERATIONS    OF    GUMS    AND    MOUTH. 

bleed  easily,  ulcerate,  and  give  off  an  offensive  odor. 
So-called  purpuric  spots,  blood  under  the  skin  and  in 
the  mouth,  soon  appear.  Sometimes  considerable  hem- 
orrhages take  place  from  the  rectum  and  nose.  Exten- 
sive ulcerations  and  infections  and  sloughs  are  devel- 
oped, and  fractures  of  the  long  bones  or  epiphyseal 
separations  are  common.  These  symptoms  increase  in 
severity  and  extend  if  the  means  of  obtaining  proper 
diet  are  not  at  hand,  and  exhausting  hemorrhages  and 
septicemia  destroy  the  patient.  If,  however,  proper 
hygienic  surroundings  and  food  can  be  obtained,  even 
the  most  deplorable  cases  soon  improve  and  recover. 

Treatment  is  chiefly  dietetic,  with  fresh  air  and  clean- 
liness. The  vegetable  acids,  lemons,  lime-juice,  and 
fruits  of  all  acid  kinds,  are  medicinal.  Salt  and  sugar 
should  be  withheld.  Strychnin  and  quinin  are  to  be 
employed.  Alcoholic  stimulants  in  moderation  may 
be  of  service.  Bitter  tonics  and  the  constructives  are 
indicated  later  on. 

Locally,  a  mouth-wash  of  listerin  3  parts  and  hydro- 
gen peroxid  i  part  will  greatly  aid  and  comfort.  Nour- 
ishing food  as  soon  as  it  is  acceptable  to  the  mouth 
should  be  insisted  on. 

SUMMARY. 

Inflammation  of  the  gums  usually  requires  removal 
of  the  cause  and  mild  mouth-gargles.  Tartar  should 
be  removed,  mercury  withdrawn,  and  sweets  and  acids 
withheld.  Hot  food  is  contraindicated.  Listerin,  chlo- 
rate of  potassium,  and,  if  necessary,  mild  cauterization 
are  indicated.  Ulcers,  simple,  syphilitic,  or  tubercular, 
require  mild,  bland,  cold  diet ;  cleanliness  and  soothing 
gargles,  with  specific  treatment  when  indicated.  Tuber- 
culosis and  malignant  lesions,  if  not  susceptible  of  ex- 
tirpation, are  treated  on  the  expectant  plan. 

Scurvy  is  diagnosticated  by  the  history,  and  should 
receive  the  standard  treatment  of  appropriate  food,  clean- 
liness, and  acid  vesfetables. 


CHAPTER   XX. 

TUMORS  OF  GUMS  AND  ALVEOLAR  BORDER,  IN- 
CLUDING DISEASE  OF  THE  BONES  OF  THE 
JAW. 

A  GENERAL  hypertrophy  of  the  gums,  occupying 
tooth  sites  of  the  alveolar  border,  is  of  rare  occurrence, 
and  when  seen,  is  usually  allied  with  some  other  indi- 
cations of  physical  ailment.  Hemophilia  and  cretinism 
may  be  associated.  Such  conditions  do  not,  as  a  rule, 
need  any  treatment,  but  well-defined  and  obstructive 
hypertrophy  should  be  removed  by  curet  or  knife  if  the 
general  condition  of  the  patient  indicates  it. 

TUMORS  OF  THE  GUMS  AND  ALVEOLAR  BORDER. 

Fibrous  and  papillomatous  outgrowth  from  the  gums, 
resembling  polypi,  are  often  seen  about  diseased  teeth. 
Usually  they  are  small,  and  can  be  trimmed  away  with 
the  scissors.  If  they  are  too  large  for  this,  a  ligature 
may  be  used  to  prevent  annoyance  from  bleeding,  after 
which  the  polyp  can  be  cut  off.  There  is  little  ten- 
dency to  return. 

A  form  of  this  growth  is  known  as  epulis.  The 
epulis,  however,  is  of  several  varieties,  and  often  ma- 
lignant. It  may  involve  the  gums  alone,  or  disease 
may  extend  into  the  bone  itself. 

In  the  simple  fibroma,  beginning  usually  as  above 
discussed,  about  a  diseased  tooth,  a  symmetric  and  hard 
growth  forms  on  both  sides  of  the  gum  border,  often 
increasing  in  size  from  that  of  the  thumb  to  a  small- 
sized  orange.  Such  growths  are  usually  painless  and 
without  ulceration,  and  are  most  frequently  seen  on  the 
lower  maxilla.  Such  conditions  are  non-malignant, 
usually  of  slow  growth,  and  without  ulceration.     When 

143 


144   TUMORS  OF  THE  GUMS  AND  ALVEOLAR  BORDER. 

early  removed  by  taking  out  the  diseased  section  of  the 
bone,  including  the  socket  of  the  tooth,  this  form  of 
epulis  does  not  recur. 


Fig.  24. — Periosteal  sarcoma,  or  epulis  (Mears). 


Fig.  25. — Periosteal  sarcoma,  or  epulis  (Mears). 

In  a  few  instances  angiomatous  growths,  rather  than 
fibrous,  make  up  the  body  of  the  epulis.  Here,  after 
the  removal,  the  actual  or  thermocautery  will  aid  in  de- 


TUMORS    OF   THE    GUiVIS    AND    ALVEOLAR    BORDER. 


145 


stroying  the  vessels  of  the  growth  at  the  margin  of  the 
wound. 

When  the  growth  has  persisted  for  a  long  period  and 
is  painful  and  perhaps  ulcerated,  a  suspicion  of  malig- 
nancy should  be  entertained  —  sarcoma  chiefly;  and 
when  in  the  presence  of  such  a  history  the  bone  is 
found  diseased,  a  free  extirpation  is  required.  Twice 
within  the  past  year  the  author  had  occasion  to  remove 
one-half  of  the  inferior  maxilla  for  fibrous  epulis,  which 


Fig.  26. — Fibroma  of  the  upper  jaw,  caused  by  blow  (Mears). 


before  operation  indicated  no  bone  disease.  In  each  case 
the  microscope  showed  round-celled  sarcoma.  Such  dis- 
ease of  the  gums  at  times  surrounds  the  dentigerous 
cysts,  and  when  such  is  the  case,  free  removal  of  mucous 
membrane,  as  well  as  the  bone,  is  required.  No  delay 
should  be  permitted  in  any  form  of  epulis,  as  the  pro- 
tracted irritation  always  keeps  up  the  growth,  which  has 
no  tendency  to  spontaneous  cure  ;  an  early  operation 
often  prevents  return  and  malignant  degeneration.  Noth- 
ing short  of  extirpation  of  half  of  the  diseased  maxilla 
in 


146   TUMORS  OF  THE  GUMS  AND  ALVEOLAR  BORDER. 

is  to  be  thought  of  in  the  presence  of  malignant  epulis. 
When  this  is  thoroughly  done,  early  recurrence  is  rare. 

This  description  is  meant  to  cover  the  various  forms 
of  epulis,  a  term  that  applies  to  any  tumor  of  the  gums, 
whether  fibrous,  angiomatous,  chondromatous,  or  malig- 
nant. The  varieties  of  these  tumors  are  characterized 
by  the  essential  features  of  each. 

The    firm,    healthy-looking    fibroma,    with    usually 


Fig.  27. — Chondroma  of  lower  jaw  (before  operation). 

broad  periosteal  attachment,  is  painless,  and  unless  irri- 
tated by  food  or  teeth,  without  ulceration.  Sometimes 
bleeding  occurs  from  bruising  by  mastication. 

The  osteoma  of  the  gums  is  not  strictly  epulis, 
although  it  requires  to  be  differentiated.  Such  tumors 
may  be  removed  with  the  chisel  if  not  too  hard. 

Chondromata  also  may  originate  from  the  periosteum, 
and  appear  as  a  lateral  growth  from  the  gums  and  jaw. 


ANGIOMATA    OF    THE    GUMS. 


147 


Fig.  28. — Chondroma  of  lower  jaw  (after  operation). 

Such  tumors  usually  belong  to  young  adult  life  ;  they  do 
not  influence  the  general  health.     Usually  they  can  be 


Fig.  29. — Osseous  tumor  of  the  right  superior  maxilla. 

removed  without  imperiling  the  jaw-bone,  especially  if 
seen  early.  Later,  removal  of  the  jaw  may  be  necessary 
if  any  operative  measures  seem  desirable. 

Angiomata  of  the  gums   are   frequently  seen  as  a 


148        TUMORS    OF    THE    GUMS    AND    ALVEOLAR    BORDER. 

form  of  epulis.  Bright-red,  sometimes  pulsating,  they 
are  chiefly  seen  in  children.  They  sometimes  attain  a 
considerable  size,  and  may  bleed  to  a  most  annoying 
degree  on  manipulation  or  mastication  of  hard  food. 
Usually  they  originate  in  the  periosteum,  or  perhaps  in 
the  pulp-cavity,  and  grow  up  around  and  between  the 
teeth.  At  times  they  are  painful  and  very  troublesome. 
Such  growths  are  apt  to  bleed  a  great  deal  on  attempt 
at  extirpation,  and  preparation  is  to  be  made  to  control 


o. ^Sarcoma  of  the  antrum  (Meais") 


by  pressure.  Removal  is  effected  by  paring  off  the 
growth  from  the  gum  and  removing  the  diseased  bone 
with  cutting  forceps  and  chisel.  Packing  with  styptic 
gauze,  if  necessary,  will  control  the  hemorrhage. 

Sarcoma  is  seen  not  only  in  the  form  of  epulis,  but 
also  in  the  central  bone  cavity,  in  the  antrum,  and  in  the 
bony  walls.  When  it  arises  from  the  lateral  periosteum 
it  may  grow  like  the  angioma,  surrounding  the  teeth  and 
even  pushing  them  in  abnormal  positions. 

The  myeloid  form  is  the  most  frequent,  and  produces  a 


ALVEOLAR    ABSCESS.  1 49 

somewhat  symmetric  swelling,  which  may  surround  the 
ramus.  Those  originating  in  the  periosteum  are  of  the 
other  varieties.  The  growth  of  these  tumors  is  irregu- 
lar, but  when  it  becomes  active,  it  progresses  rapidly. 
The  softer  forms,  in  which  there  is  less  fibrous  tissue 
but  more  vascularity,  grow  more  rapidly  than  the 
myeloid. 

The  diagnosis  is  often  obscure  in  the  earlier  stages. 
Sarcoma  may  be  mistaken  for  fibroma  and  chondroma. 
The  rapidity  of  growth  and  the  evident  infiltration  with 
surrounding  tissue,  as  well  as  the  influence  on  the  gen- 
eral health,  determine  the  nature. 

Treatment. — The  early  and  complete  removal  of  these 
growths  is  the  only  treatment.  If  the  tumor  is  well 
encapsulated,  without  infiltration,  a  removal  of  the 
attachment  with  a  piece  of  the  bone  may  secure  immu- 
nity from  return  ;  but  in  the  myeloid  form,  and  when- 
ever the  surrounding  tissues  of  the  bone,  periosteum, 
and  mucous  membrane  are  infiltrated  and  enlarged,  the 
ramus  of  the  lower  jaw,  or  the  half  of  the  upper,  will 
require  removal. 

Extensive  sarcoma  of  the  upper  jaw,  especially  when 
the  cavity  of  the  antrum  is  involved,  offers  little  pros- 
pect even  with  extirpation  of  the  diseased  maxilla,  and 
it  is  often  questionable  surgery  to  excise  the  superior 
maxilla. 

The  starvation  of  such  growths  by  the  ligation  and 
extirpation  of  the  external  carotid  artery  is  recommended 
as  having  given  good  results  :  and  wherever  the  bone  is 
removed,  it  should  be  preceded  by  this  step  not  only  to 
secure  better  hemostasis,  but  also  to  deprive  the  situation 
of  the  growth  of  nutrition. 

ALVEOLAR   ABSCESS. 

By  this  is  meant  suppuration  in  the  alveolus  of  a 
tooth,  usually  first  involving  the  periosteum  of  the 
tooth  and  its  covering,  as  well  as  the  lining  of  the 
alveolus.      It  is  caused  by  infection  of  this  highly  favor- 


150       TUMORS    OF    THE    GUMS    AND    ALVEOLAR    BORDER. 

able  spot,  by  entrance  from  without  through  diseased 
tooth-cavities,  either  filled  or  unfilled ;  or,  as  sometimes 
happens,  lowered  vitality  in  a  bruised  alveolus  or  root 
will  permit  circulating  germs  to  colonize  ;  suppurative 
inflammation  thus  arises. 

Symptoms. — Almost  every  one  has  suffered  from  this 
form  of  toothache.  First,  there  is  acute  throbbing  pain, 
with  exquisite  tenderness  of  the  diseased  tooth  to  the 
touch  ;  early  heat,  swelling,  and  redness  of  the  gum 
set  up ;  even  swelling  of  the  cheek  is  seen,  although 
not  so  marked  in  the  earlier  stage.  The  tooth  seems 
lengthened,  and  indeed  is  somewhat  pushed  out  from 
the  alveolus.  If  these  symptoms  disappear  without 
suppuration,  which  is  not  often  the  case  in  the  presence 
of  infection,  the  pain  and  swelling  subside.  In  those 
cases,  however,  in  which  an  abscess  forms,  the  swelling 
of  the  face,  as  well  as  of  the  gum,  goes  on.  Even  drop- 
sical infiltration  of  the  eyelid  and  cheek  supervenes. 
The  body-temperature  is  often  elevated.  Although 
the  severity  of  the  pain  diminishes,  it  is  usually  worse 
at  night,  and  indicates  the  throbbing  of  an  abscess. 
Fluctuation  may  be  made  out  where  pus  points.  This 
is  most  commonly  at  the  mucous  junction  of  the  gum 
and  cheek,  but  at  times  it  is  on  the  tongue  side  or 
through  the  pulp-cavity  of  the  tooth.  Sometimes  it 
penetrates  the  alveolar  wall  and  may  perforate  the 
cheek,  or  in  rare  instances  burrow  along  down  the  jaw 
into  the  neck.  In  the  upper  jaw  escape  of  pus  may 
take  place  over  the  roof  of  the  mouth,  or  even  into 
antral  or  nasal  cavities.  These  unusual  openings  are 
seen  only  in  severe  and  grossly  neglected  abscesses,  but 
sinuses  in  the  above-mentioned  situations,  which  have 
no  other  history,  should  be  carefully  traced  to  determine 
the  possible  connection. 

Diagnosis. — Usually  the  history,  severe  toothache, 
pain  and  tenderness,  with  the  swollen  gum  direct  a 
suspicion  to  beginning  abscess,  and  often  fluctuation 
will  be  detected.     In    neglected   cases,  where   the   ab- 


v^ 


DISEASES    OF    THE    BONES    OF    THE    JAW.  151 

scess  has  ruptured  within  the  mouth  and  much  relief 
has  resulted,  careful  inspection  will  disclose  a  small 
sinus  through  which  compression  will  express  some 
pus.  Tenderness  of  the  tooth  to  tapping  or  compres- 
sion will  usually  indicate  the  origin  of  the  disease. 

Treatment. — If  the  tooth  be  not  too  much  diseased, 
temporizing  measures  may  be  employed,  the  abscess 
opened  at  the  gum  border,  and  then  perhaps  the  tooth 
may  be  saved  and  later  filled.  Before  the  occurrence 
of  suppuration,  warmth  to  the  face,  a  hot-water  bag, 
or  a  dry  hot  bag  will  alleviate  the  pain,  while  treatment 
of  the  cavity  may  be  conducted  as  appears  rational.  If, 
however,  suppuration  appears  probable,  incision  should 
be  made  for  exploratory  purposes,  and  unless  free  drain- 
age can  be  thus  obtained,  the  tooth  should  be  extracted. 
When  the  tooth  is  hopeless,  it  should,  under  any  cir- 
cumstances, be  promptly  and  completely  extracted  and 
the  alveolar  cavity  cureted.  If  the  abscess  has  dis- 
charged into  the  cheek  or  mouth  and  a  sinus  persists, 
it  must  be  opened  up  under  an  anesthetic  and  scraped 
out,  and  put  in  a  condition  to  heal. 

DISEASES  OF  THE   BONES  OF  THE  JAW. 

Necrosis  and  periosteal  inflammations  of  the 
bones  of  the  jaw  are  nearly  always  syphilitic  when  not 
due  to  traumatism,  except  in  some  localities  where  phos- 
phorus workers  contribute  to  the  number. 

Inflammation  of  the  periosteum  is  not  common  aside 
from  these  causes,  but  the  symptoms  are  the  same  even 
if  from  simple  traumatism :  pain  and  swelling,  more 
distressing  at  night ;  tenderness,  which  enables  one  to 
locate  the  spot  of  inflammation  ;  and  probable  suppu- 
ration. Here  prompt  and  free  incision,  with  irrigation 
and  drainage,  is  indicated. 

In  the  chronic  form,  tubercular,  syphilitic,  or  from 
phosphorus,  rational  treatment  on  established  lines  is 
indicated. 

Necrosis  may  follow  the  periostitis  when  treatment 


152       '  DISEASES    OF    THE    BONES    OF   THE   JAW. 

is  neglected.  The  symptoms  are  suppuration,  usually 
through  a  sinus,  and  small  in  amount,  loosening  of  the 
teeth,  oflfensive  breath,  and  the  sensation  of  dead  bone 
to  the  probe.  In  syphilitic  and  phosphorus  necrosis 
the  history  is  usually  obtained.  Mercury  and  scurvy 
may  be  the  producing  factors.  Under  any  circum- 
stances the  history  should  be  carefully  obtained  to  de- 
termine the  diagnosis. 

Treatment. — When  loose  pieces  of  bone  are  located, 
they  should  be  removed,  but  force  should  not  be  made, 
nor  should  operative  interference  be  undertaken,  until 
the  sequestrum  has  well  separated.  The  general  health 
should  be  supported,  and  measures  for  cleanliness  per- 
severed in  until  the  dead  bone  can  be  felt  to  move 
freely. 

Phospliorus-necrosis  is  a  far  less  frequent  lesion 
than  formerly,  because  of  the  careful  prophylactic  meas- 


FiG.  31. — Phosphorus-necrosis  of  one-half  of  the  lower  jaw  (Mears). 

ures  that  are  taken  in  all  factories  where  the  drug  is 
used.  The  prophylaxis  consists  in  ventilation,  clean- 
liness, and  early  recognition  of  the  symptoms,  as  well 
as  the  use  of  more  easily  oxidized  phosphorus  than 
formerly. 

The  symptoms  in  those  exposed  to  phosphorus  fumes 
are,  first,  painful  tenderness  in  the  gums  and  jaws,  in  the 


CYSTS    OF    THE    ALVEOLAR    BORDER.  I53 

beginning  occasionally,  later  constantly;  redness  of  the 
gums;  swelling,  ulceration,  and  discharge  of  pus,  which 
is  offensive  and  unhealthy.  I^ater  on  necrosis  may  in- 
volve extensive  portions  of  either  jaw,  and  a  sequestrum 
form.  The  general  health  suffers,  and  exhaustion  with 
septic  infection  may  precede  death.  If  the  articulation 
of  the  lower  jaw  becomes  involved,  false  ankylosis  may 
be  present.  Slough  of  muscle  and  cellular  tissue  may 
succeed  the  infection,  and  a  slow  process  of  destruction 
of  the  soft  parts,  as  well  as  of  bone,  may  set  up. 

The  course  of  phosphorus-necrosis  is  essentially 
chronic  and  often  lasts  for  years. 

Diagnosis  is  made  chiefly  by  the  history.  The  granu- 
lar bone  deposits  over  the  dead  surface  are  peculiar  to 
this  form  of  necrosis. 

Treatment. — In  the  early  stages  cleanliness  and  careful 
attention  to  the  teeth,  wiih,  of  course,  immediate  re- 
moval of  the  cause.  All  hopeless  teeth  should  be 
carefully  extracted,  so  as  to  leave  no  open  space  for 
infection;  cavities  should  be  carefully  protected  with 
temporary  fillings.  Astringent  and  antiseptic  mouth- 
washes should  be  employed  regularh-.  Constitutionally, 
turpentine  is  recommended  as  an  antidote.  After  the 
period  of  inflammation  is  passed,  the  ordinary  operative 
measures  are  to  be  applied  to  the  diseased  bone. 

Cysts  of  the  alveolar  border  are  of  two  kinds: 

First^  those  that  are  inflammatory  in  character  and 
begin  at  the  root  of  a  diseased  tooth,  within  the  peri- 
dental membrane.  Usually  such  cysts  are  small  and  are 
not  noticed  until  the  tooth  is  loosened.  At  other  times 
they  may  even  extend  to  and  occupy  the  whole  antrum. 
Second^  the  so-called  dentigerous  cyst,  referred  to  under 
another  caption.  These  growths  originate  from  the 
inner  surface  of  the  enamel  covering  of  the  tooth,  and 
contain  a  clear  fluid,  which,  if  not  set  free  by  the  erup- 
tion of  the  tooth,  collects  around  it  and  forms  a  cyst 
which  incloses  the  tooth.  The  tooth  later  becomes 
loosened  and  may  fall  into  the  cyst  cavity.     Usually  the 


154 


DISEASES    OF    THE    BONES    OF    THE   JAW. 


site  of  these  cysts  is  in  the  anterior  teeth.  They  may 
remain  limited  to  the  alveolar  structure,  or  may  invade 
the  antrum  or  protrude  into  the  mouth. 

The  symptoms  are  indication  of  a  firm,  but  thin- 
walled,  fluctuating  tumor,  which  is  painless  and  grows 
slowly,  and  occupies  the  site  of  an  absent  permanent 
tooth.  The  use  of  an  exploring  trocar  in  the  tumor 
'will  determine  its  character.  Such  conditions  are  im- 
portant in  diagnosis,  chiefly  because  the  larger  ones  may 


Fig.  32. — Cystic  tumor  of  the  jaw,  probably  dentigerous  (Warren  Museum). 

be  mistaken  for  malignancy,  and  induce  extirpation  of 
the  jaw  unnecessarily. 

The  treatment  of  the  inflammatory  cyst  is  usually 
nothing  more  than  extraction  of  the  loosened  and  dis- 
placed tooth.  The  dentigerous  cysts  require  incision 
with  a  strong  knife  or  chisel,  and  curetment  of  the 
cavity,  irrigation,  and  packing  with  gauze  wet  with  a 
disinfecting  solution.  Excess  of  bone  should  be  removed 
with  a  gouge,  that  the  cavity  may  be  obliterated. 


SUMMARY.  155 

SUMMARY. 

Epulis  is  a  tumor  of  the  gums  aud  may  be  fibrous, 
mucous,  angiomatous,  cartilaginous,  or  bony;  it  may  be 
benign  or  malignant.  Usually  it  is  easily  removed, 
which  should  be  the  treatment,  with  wide  excision  if 
there  is  doubt  as  to  malignancy. 

Sarcoma  may  involve  the  antrum  as  well  as  the  gums, 
and  are  diagnosticated  by  the  rapid  growth  and  large 
size  they  quickly  attain.  Early  and  complete  extirpation 
is  the  only  hope.  Ligation  of  carotids  in  inoperable 
growths  is  recommended. 

o 

Alveolar  abscess  is  the  ordinary  gum-boil.  It  may  at 
times  penetrate  the  cheek,  or  even  in  neglected  cases 
open  in  the  roof  of  the  mouth.  Treatment  consists  in 
immediate  extraction  of  the  tooth  if  diseased  too  much 
to  save;  and  if  the  bone  is  diseased,  incision  and  the 
curet. 

In  periostitis  or  necrosis  diseased  bone  should  be  re- 
moved as  soon  as  loose. 

Phosphorus-necrosis  v&xd.x^.  Treatment  rational:  clean- 
liness, turpentine  internally,  and  removal  of  sloughs. 

Cysts  due  to  disease  of  tooth-roots  or  inclusion  of  un- 
developed structures  should  be  cureted  and  packed. 
Dead  bone  should  be  removed. 


CHAPTER    XXI. 

SURGICAL  LESIONS  OF  THE  MOUTH  AND  FACE. 

Tuberculosis  of  the  skin  is  seen  on  the  face  in  the 
form  of  lupus  vulgaris,  often  in  connection  with  tuber- 
cular manifestations  elsewhere  in  the  patient,  although 
it  is  usually  a  primary  manifestation.  It  is  seen  on  the 
nose,  eyelids,  and  cheeks.  The  bacillus  is  not  often 
found  in  lupus,  as  usually  the  germs  of  suppuration 
have  destroyed  them.  The  simple  form  of  lupus  may 
be  manifested  merely  as  reddish-brown  nodules  under  the 
surface  of  the  skin,  which,  while  not  showing  ulceration, 
may  be  broken  down  by  slight  pressure.  These  nodules 
sometimes  cicatrize  and  get  well.  At  other  times,  how- 
ever, usually  after  a  long  time,  ulceration  sets  up.  A  red- 
dish, granular  ulcer  may  extend  until  considerable  por- 
tions of  the  face  are  involved.  This  is  hipiis  exedens  and 
simulates  malignancy.  Parts  of  the  ulcer  may  heal  while 
the  other  extends.  In  this  form  the  ulcer  takes  on  a  ser- 
piginous growth,  undermining  and  producing  extensive 
destruction  of  the  bone,  resembling  the  rodent  ulcer  of 
epithelioma.  In  the  hypertrophic  variety  warty  tuber- 
cles form,  simulating  a  species  of  elephantiasis  ;  later, 
these  ulcerate. 

•  Cicatrization  follows  in  parts  of  these  ulcers,  and  often 
great  deformity  is  produced.  Portions  of  the  nose  and 
eyelids  are  eaten  away.  In  the  exedens  variety  the 
progress  is  slow  and  spreads  by  gradual  extension  in 
every  direction.  It  is  to  be  distinguished  from  epithe- 
lioma by  the  absence  of  pain,  lymphatic  involvement, 
and  tendency  to  cicatrization.  Syphilis  is  distinguished 
by  the  history,  painlessness,  and  response  to  specific 
measures. 

156 


EPITHELIOMA. 


157 


The  treatment  for  skin  tuberculosis  is  free  excision 
rather  than  curetment,  which  should  be  reserved  for 
cases  insusceptible  of  complete  removal  with  the  knife. 
The  injection  of  antitubercular  serum  is  reported  to  have 
had  favorable    effect   upon    these   manifestations.     The 


Fig.  ;^;}. — Sarcoma  cutis  (Matas). 


injection    is  also    helpful  as  a  diagnostic,    producing  a 
reaction  in  the  presence  of  tuberculosis. 

Epithelioma. — Epithelioma  of  the  face  is  usually 
single,  beginning  as  a  wart  or  fissure,  either  on  the  lip 
or  cheek,  and  growing  very  slowly  with  a  localized 
ulceration  and  a  tendency  to  an  elevation  or  tumor 
growth,  with  lancinating  pain,  at  times,  and  a  serous  or 
watery  discharge  from  the  sore.  After  a  few  months, 
more  or  less,  glandular  sympathy  is  shown  bv  the 
lymphatics.     The  growth  of   epithelioma  ordinarily  is 


iS8 


SURGICAL    LESIONS    OF   THE    MOUTH    AND    FACE. 


slow,  and  years  may  elapse  before  cachexia  and  sepsis 
carry  off  the  victim. 

In  the  rodent  ulcer  the  appearance  is  very  much  like 
that  of  lupus  exedens,  except  that  ulceration  of  the 
rodent  cancer  does  not  cicatrize,  and  usually  has  more 
discharge  and  pain. 

The  diagnosis  of  facial  epithelioma  is  usually  unmis- 


FlG.  34. — Rodent  ulcer,   originating  in  the  scar  from  a  gunshot  wound  of 
forty  years'  duration  ;   no  infection  of  the  cervical  glands  (Warren). 

takable.  It  is  seen  in  old  people,  commonly  as  a  wart  or 
fissure,  grows  slowly,  with  later  involvement  of  lym- 
phatics. Chancre  is  diagnosed  by  history,  rapid  growth, 
early  involvement  of  lymphatics,  and  response  to  specific 
medication.  Treatment  is  early  and  complete  extirpa- 
tion ;  the  continued  administration  of  arsenic  for  months 
after  removal  is  advocated,  but  appears  unnecessary.   The 


CAXCRUM    ORIS. 


159 


Rontgen  rav  is  advocated  for  both  tubercular  and  malis^- 
nant  ulcerations. 

Chancre  of  the  I/ip. — This  condition,  while  rare,  has 
sometimes  been  mistaken  for  epithelioma  and  extir- 
pated, with,  of  course,  no  real  benefit.  The  sore  is 
inflamed  ;  usually,  too,  it  is  quite  sensitive,  but  not  pain- 
ful. Ulceration  with  the  characteristic  crater  is  seen. 
The  growth  is  rapid,  and  lymphatic  involvement  occurs 
often  within  two  weeks  ;  other  symptoms  soon  appear, 
and  the  growth  yields  to  antisyphilitic  treatment.  In 
young  people  a  recent  growth  should  never  be  pro- 
nounced epithelioma  without  a  course  of  mercury. 


Fig.  35. — Cliancre  of  ihe  upper  lip  (Porter). 

Cancrum  oris,  or  noma,  is  a  gangrenous  ulceration, 
most  likely  of  mycotic  source,  although  the  germ  is  not 
yet  certainly  isolated.  It  grows  with  great  rapidity,  and 
is  attended  with  profound  constitutional  symptoms  earlv 
in  the  attack.  It  is  seen  rarely  before  the  third  vear, 
and  not  later  than  the  tenth,  in  feeble,  badly  nourished 
children.  Frequently  it  occurs  in  the  course  of  an  acute 
infectious  fever.      Death  usuallv  results  within  a  week. 


i6o 


SURGICAL    LESIONS    OF    THE    MOUTH    AND    FACE. 


The  treatment  consists  in  early  removal  of  the  slough, 
cauterization  with  nitric  acid,  and  the  administration 
of  stimulants. 

Other  forms  of  local  sloughs  on  the  face  are  very  rare. 

Acne  Rosacea. — This  is  a  chronic  hyperemia,  usu- 
ally an  inflammation  of  the  epithelial  layer  of  the  skin, 
seen  chiefly  at  the  tip  of  the  nose,  but  at  times  on  the 
cheeks  and  chin.  In  the  early  stages  it  appears  as  a 
mild    redness,   disappearing    on    pressure,   and    always 


Fig.  36. — Small  round-cell  sarcoma  (Weir). 


painless.  After  a  time  the  skin  becomes  roughened 
and  scaly,  and  the  local  blood-vessels  permanently  di- 
lated ;  livid  pimples  appear  over  the  field  of  irritation. 
The  disease  is  very  disfiguring  at  times,  but  has  no 
tendency  to  ulceration,  although  in  a  more  aggravated 
form  productive  of  soft,  fleshy  growths  from  the  size  of 
a  pea  to  that  of  an  egg^  which  may  form  on  the  nose  and 
chin.     This  condition  is  called  rhiiwphyma. 


ACNE    VULGARIS. 


i6i 


The  disease  is  essentially  chronic,  and  usually  does 
not  completely  yield  to  treatment  until  middle  age. 

Diagnosis  from  lupus  is  not  always  clear  before  ulcera- 
tion in  that  affection.  Tubercular  ulcerations,  as  well  as 
those  of  syphilis,  declare  themselves  by  breaking  down. 
The  excavations  in  acne  rosacea  are  always  elevated, 

Rhinophyma  may  simulate  malignant  tumors.  The 
history   of    previous    course   will   usually   differentiate. 


Fk;.  37. — Small  round-cell  Sarcoma  (Weir). 

Treatment. — The  diet  must  be  regulated,  constipation 
corrected,  and  alcoholic  stimulants  be  given  up.  Lo- 
cally, sulphur  in  powder,  ichthyol  in  5  to  8  per  cent, 
ointment,  applied  when  convenient,  and  washing  with 
hot  water  and  strong  soap  are  measures  of  service,  but 
the  disease  is  very  stubborn.  Electrolysis  is  sometimes 
of  service.      Excision  is  to  be  employed  in  rhinophyma. 

Acne  Vulgaris.— The  dentist  will  often  be  asked 
advice  about  this  very  common  affection.  It  consists 
n 


l62  SURGICAL    LESIONS    OF    THE    MOUTH    AND    FACE. 

in  a  papular  and  pustular  eruption  on  the  forehead  and 
face.  It  is  seen  usually  between  the  ages  of  fourteen  to 
twenty-five,  rarely  later  than  thirty,  in  both  sexes.  It 
is  usually  due  to  the  disease  of  the  sweat-follicles,  which 
are  often  filled  up  with  the  so-called  comedo,  or  flesh- 
worm,  which  is  a  plug  of  sebaceous  matter  obstructing 
the  duct  of  the  gland. 

Some  of  these  comedos  are  deep-seated,  and  suppu- 
ration, which  may  be  several  days  reaching  the  surface, 
will  occasion  pain  and  soreness. 

The  course  is  always  chronic,  and  not  infrequently 
scars  and  discolorations  may  result  in  considerable  dis- 
figurement for  months  or  years.  Eventually  the  affec- 
tion disappears.  The  condition  is  due  to  disturbance 
of  digestion  ;  rich  food,  sweets  and  spices,  constipation, 
are  all  factors  in  establishing  acne,  although  often  the 
cause  cannot  be  traced. 

Treatment  is  eminently  unsatisfactory,  for  although 
a  helping  influence  is  not  difficult  to  obtain,  yet  cure 
of  this  distressing  and  humiliating  eruption  is  often 
long  enough  deferred  to  make  heart-sick  the  patient 
and  the  physician. 

Constitutionally,  care  in  diet  and  attention  to  the 
bowels  is  most  important.  The  sulphid  of  calcium  in 
^-grain  doses  four  times  daily,  and  5-drop  doses  of  Fow- 
ler's solution  of  arsenic  three  times  daily,  are  among  the 
standard  measures  internally.  Locally,  washing  the 
skin  twice  daily  with  strong  soap,  expressing  gently 
the  comedos  as  soon  as  they  can  be  got  out,  opening 
pustules  or  even  inflamed  papules  with  a  small  tenot- 
omy knife,  the  application  of  hot  gauze  pads  to  inflamed 
papules,  precipitated  sulphur  over  the  face  at  night,  are 
among  the  most  efficacious  measures. 

SUMMARY. 

Lupus^  which  is  seen  in  several  forms,  is  a  tubercular 
germ,  sometimes,  as  in  the  lupus  exedens,  of  a  malig- 
nant tendency.     It  is  always  difficult  to  eradicate. 


SUMMARY.  163 

Epithelioma  is  more  painful,  and  has  a  later  glandular 
involvement,  with  cachexia  ;  the  rodent  ulcer  is  a  form 
between  the  two  in  point  of  virulence. 

Cancrum  oris  is  a  local  gangrene  of  the  cheek,  rapidly 
destructive,  and  requiring  prompt  cauterization. 

Acne  vulgaris  is  the  ordinary  pimple  of  the  face,  due 
to  comedos.  It  is  best  treated  by  hot  bathing,  strong 
soap,  and  germicides. 

Acne  rosacea  is  a  lupus-like  redness  of  the  cheek  or 
nose  or  of  both.  Alcohol  and  rich  diet  add  to  it ;  also 
gouty  tendency.  Treatment  is  abstinence  and  purga- 
tion. 


CHAPTER   XXII.   * 
SURGICAL    LE5I0NS   OF   THE   FACE    (Continued). 

Sebaceous  Tumors,  or  Steatoma. — These  are  oval 
and  globular-shaped  cysts,  varying  in  size  from  that  of 
a  pea  to  that  of  a  hen's  egg^  and  containing  sebaceous 
material  in  more  or  less  cheesy  or  fluid  state.  They  are 
retention  cysts  of  sebaceous  glands.  Although  these 
tumors  are  most  common  in  the  scalp,  they  are  fre- 
quently seen  on  the  face  and  neck,  as  well  as  on  other 
parts  of  the  body.  They  are  practically  large  comedos, 
although  often  containing  small  hairs  and  fat-globules. 

The  diagnosis  of  steatoma  is  easy.  These  tumors 
are  usually  knob-like,  painless,  and  moderately  mov- 
able. They  have  often  the  peculiar  shiny  appearance 
of  stretched  skin.  Fluctuation  can  sometimes  be  dis- 
tinguished. Fatty  tumors  are  excluded  by  their  greater 
freedom  of  motion  and  more  irregular  and  flattened  con- 
tour. Steatoma  are  often,  indeed  usually,  multiple.  In 
the  more  chronic  growths,  sometimes  ulceration  takes 
place,  with  escape  of  contents. 

Treatment  is  by  incision  of  the  skin  without  opening 
the  cyst-wall,  which  is  easily  separated  by  the  handle 
of  the  scalpel  from  the  skin,  and  the  unruptured  cyst 
is  readily  enucleated.  The  cyst-wall  must  be  removed 
in  entirety,  else  the  tumor  will  return.  Sometimes, 
when  it  is  inadvertently  ruptured,  it  may  have  to  be 
pulled  away  piecemeal.  If  the  sac  is  not  wholly  re- 
moved, it  should  be  cauterized  with  carbolic  acid  or 
even  nitric  acid.  Usually  there  is  little  trouble  attend- 
ing extirpation.     A  stitch  or  two  will  insure  union. 

Keloid. — True  keloid  develops  often  without  obvious 
cause,  although  usually  some  injury  can  be  traced.  It 
appears  as  an  oblong  growth  of  fibrous  tissue,  elevated 

164 


KELOID. 


l6: 


to  one-fourth  of  an  inch  or  more,  and  looking  like  scar- 
tissue.  It  is  sometimes  linear,  sometimes  flat,  irregular, 
often  sending  out  prolongations.  Usually  the  growth 
is  firm,  elastic,  devoid  of  hair,  and  painless ;  sometimes 


Fig.  3S.- 


-General   keloidal   disease  in  a  negro,  with  raolluscum   fibrosum 
(Matas). 


it  presents  an  itching  or  burning  sensation.  They  grow 
slowly,  and  usually  remain  small.  Sometimes  they  are 
multiple.  They  do  not  ulcerate.  Keloids  are  much 
more  frequent  in  the  negro  than  in  the  white.  They 
are  seen  chiefly  on  the  chest  and  neck  ;  less  frequently 


1 66  SURGERY   OF    THE    NOSE. 

on  the  face  and  ears.  It  is  not  at  all  a  common  affec- 
tion, although  scar  tissue,  after  a  lapse  of  time,  often 
assumes  a  keloid  appearance,  although  not  strictly  a 
new  growth.  The  diagnosis  is  not  difficult  to  one  who 
has  once  seen  similar  growths.  There  is  no  treatment 
to  be  approved,  as  it  usually  recurs  after  excision.  It  is 
to  be  regarded  as  a  permanent  lesion. 

SURGERY  OF  THE  NOSE. 

Tumors  of  the  external  surface  of  the  nose  are  rarely 
any  other  form  except  the  lipoma  and  the  papilloma,  to 
which  reference  has  already  been  made.  Malignant 
growths  are  rarely  seen  within  the  nose,  although  epi- 
theliomatous  patches  are  common  on  the  skin  surface. 
IvUpus  and  syphilis  have  been  described. 

Polypi  are  found  very  frequently  in  the  nose.  They 
are  almost  always  benign.  The  gelatinous  form  is 
small  and  soft,  frequently  multiple,  and  appears  as  a 
bluish  mass  springing  from  the  mucous  membrane  of 
the  middle  turbinated  bone.  Upon  inspection  in  a  good 
light  they  are  easily  seen.  They  are  painless,  and 
usually  give  trouble  only  by  stopping  up  the  nose. 

Treatment  is  removal  with  a  snare  passed  over  them. 
The  smaller  may  be  readily  twisted  off  with  forceps. 

Fibromatous  polypi  are  large,  firm  tumors,  usually 
single,  and  often  of  sufficient  size  to  depress  the  palate, 
or  more  commonly  push  out  the  nasal  bone.  They, 
too,  are  usually  painless,  but  firmly  obstruct  and  distort 
the  nose.  They  are  much  more  difficult  to  deal  with, 
as  they  have  firm  and  extensive  attachments.  The 
galvanocautery  is  the  best  agent  to  remove  them. 

Deformity  of  the  nose  is  congenital ;  it  can  be  ac- 
quired either  by  disease  or  traumatism.  In  many  in- 
stances great  mental  distress  is  felt  by  the  patient 
because  of  a  nasal  defect  easily  remedied. 

The  most  common  deformities  are  saddle-nose,  pug- 
nose,  and  hump-nose.  Each  of  these  conditions  is  sus- 
ceptible of  great  relief  by  properly  directed  surgery. 


DEFORMITY    OF   THE    NOSE. 


167 


The  short  nose  may  be  lengthened,  the  redundancy 
may  be  removed  from  the  large  nose  by  careful  and 
well-directed  dissection,  and  a  wire,  platinum,  or  cel- 
luloid support  may  be  introduced,  which  will  hold  up 
the  flat  nose.  These  various  mechanical  supports  are 
often  eminently  satisfactory,  and  may  serve  a  life-time 
without  producing  irritation.     Of  course,  absolute  asep- 


FlG.  39. — Deformity  due  to  congenital  syphilis  ;  insertion  of  platinum  support 

(Weir). 


sis  is  necessary  in  the  introduction,  and  in  instances 
where  irritation  sets  up  later  the  support  must  be  re- 
moved. The  depressions  in  the  nose  due  to  congenital 
syphilis  of  the  bones  are  best  remedied  in  this  way. 
When  a  destructive  process  of  tertiary  syphilis  has 
destroyed  the  soft  parts  as  well,  plastic  operations  are 
required.  Roberts  and  Weir  have  suggested  and  exe- 
cuted  plastic   operative   steps   for    such    deformities   as 


i68 


SURGERY    OF    THE    NOSE. 


Fig.  40. — Result  after  insertion  of  platinum  support  (Weir) 


Fig.  41. — Angular  deformity  of  the  nose  (Curtis). 


DEFLECTION  OF  THE  NASAL  SEPTUM. 


169 


Fig.  42. — Result  after  removal  of  the  bonv  hump  (Curtis). 

saddle-nose,  which  accomplish  the  correction,  but  leave 


a  scar. 


Fig.  43. — Flattening  of  the  nose  from  destruction  of  the  cartilaginous  septum 
by  syphilitic  disease. 

Deflection  of  the  nasal  septum  to  some  degree  is 
so  common  as  to  be  almost  universal,  but  when  this  is 
pathologic,  either  from   accident  or  disease,  it  requires 


I/O  SURGERY    OF    THE    NOSE. 

attention.  Although  not  nearly  so  common  in  children 
as  in  adults,  it  is  in  them  a  more  serious  interference 
with  health,  disturbing  the  lymphatics  of  the  posterior 
nasal  and  pharyngeal  region  by  occasioning  insufficient 
oxygenation,  encouraging  abnormal  growths  and  ton- 
sillar hypertrophy. 

The  occurrence  of  persistent  headaches,  chronic  eye 
pains,  asthmatic  symptoms,  and  especially  disturbed 
respiratory  action  or  persistent  catarrhal  lesions  of  the 
nasal  tract  indicate  operative  steps.  Although  many 
methods  have  been  employed  to  remove  the  spur  or 
bony  deflection,  the  most  satisfactory  is  the  revolving 
saw  and  surgical  engine,  which  cuts  away  the  septum 
and  leaves  a  permanent  perforation  or  fenestrum.  The 
same  may  be  done  with  punch  forceps.  Cocain  anes- 
thesia is  always  required.  Such  steps  are  troublesome 
and  bloody,  and  the  special  apparatus  of  the  rhinologist 
is  required  to  facilitate  them. 

Chronic  empyema  of  the  frontal  sinus  is  rare. 
It  is  suggested  by  persistent  dull  pain  over  the  region, 
with  tenderness  and  perhaps  bulging,  with  accompany- 
ing mental  depression,  and  an  ever-present  sense  of 
weight  in  the  forehead  and  root  of  the  nose.  A  dis- 
charge of  pus  from  the  nose  not  connected  with  dis- 
ease of  the  antrum  and  not  local  catarrh  is  to  be  referred 
to  empyema  of  the  frontal  sinus. 

Treatment. — When  the  diagnosis  is  determined  an 
opening  should  be  made  over  the  sinus,  and  a  commu- 
nication with  the  curet  established  between  the  two 
cavities.  The  canals  should  then  be  well  washed  out, 
and  drainage  established  or  else  the  canals  packed  with 

gauze. 

SUMMARY. 

Sebaceous  tumors  of  the  face  require  enucleation. 
Keloids  are  rare  in  the  white  race,  and  the  treatment 
is  unsatisfactory.  Surgery  of  the  nose  is  productive  of 
great  benefit  in  many  ways.  The  special  lesions  should 
be  studied  individually. 


CHAPTER   XXIII. 
CLEFT=PALATE.— HARELIP. 

CLEFT=PALATE. 

ClEFT-pai^aTE  is  a  congenital  defect  in  the  roof  of 
the  mouth,  sometimes  involving  the  alveolar  margin  of 
the  superior  maxilla,  often  extending  posteriorly  through 
the  soft  palate  and  uvula.  It  is  usually  complicated 
with  harelip. 

Plastic  operations  for  the  closure  of  the  cleft  have 
been  more  or.  less  popular  since  the  middle  of  the 
eighteenth  century,  but  with  the  progress  of  prosthetic 
dentistry  mechanical  obturators  have  superseded  opera- 
tive measures  in  very  many  of  the  worst  instances. 
This  is  particularly  true  of  neglected  cases,  in  which 
the  condition  is  allowed  to  go  on  untreated  to  adoles- 
cence. Undoubtedly  it  is  wise  surgery  to  operate  early 
on  suitable  cases,  and  it  is  the  belief  of  the  writer  that 
not  only  the  correction  of  the  altered  voice,  but  also  the 
general  vigor  of  the  patient,  demands  early  interference. 

Lane  has  shown  how  imperfect  oxygenation  and  con- 
sequent infection  of  the  nasal  and  pharyngeal  respira- 
tory apparatus  result  from  obstructions  in  and  malforma- 
tions of  the  nasal  canals,  with  consequent  deterioration 
of  health.  There  is  no  good  reason  why  operations 
should  not  be  done  in  the  first  three  months  of  in- 
fantile life,  and  there  are  abundant  proofs  that  it  is 
then  equally  successful  and  facilitates  feeding,  breathing, 
and  phonation. 

In  the  simple  form  of  cleft-palate  of  the  soft  parts 
only  the  operation  is  termed  staphylorrhaphy .  When 
the  defect  is  central,  splitting  the  uvula  and  velum  up 
nearly,  or  quite  to,  the  posterior  bony  border,  it  may 
easily  be  closed  by  freshening  the  edges  and  suturing. 

171 


1/2 


CLEFT-PALATE, 


In  the  infant  chloroform  should  be  administered,  and  the 
patient  placed  on  the  back,  with  the  head  hanging  a 
little  over  the  end  of  the  table  where  the  operator  sits. 
The  edges  of  the  split  should  be  freely  trimmed  from 
the  palate  margin  downward,  first  on  one  side,  then  on 
the  other;  a  strip,  -^  to  -^^  of  an  inch  wide,  is  cut  away- 
down  to  "1^  of  an  inch  of  the  free  edge,  and  the  strips 
allowed  to  drop  down.  Sutures  of  fine  chromicized  cat- 
gut are  now  introduced  from  the  upper  margin  through 
the  dependent  strips  (which  form  a  new  uvula  and  velum) 
and  tied.  If  the  strips  are  longer  than  necessary,  the 
redundancy  may  be  cut  off.  Usually,  by  the  end  of  two 
weeks,  the  catgut  will  be  absorbed,  but  if  any  trouble 


Fig.  44.- 


-The  hollow  bulb  or  hard-rubber  appliance  used  in  the  mechanical 
treatment  of  cleft-palate  (Moriarty). 


arises,  it  may  be  removed  in  from  six  to  ten  days.  It  is 
well  to  spray  the  wound  with  diluted  peroxid  of  hydro- 
gen every  three  or  four  hours  after  the  first  day. 

The  operation  upon  the  hard  palate  is  termed  urano- 
plasty. The  writer  prefers  the  steps  as  indicated  by 
Lane.  Under  an  anesthetic  (chloroform),  with  the  child 
in  the  position  just  indicated,  and  a  good  mouth-gag 
between  the  jaws,  a  free  incision  is  made  on  one  side 
to  the  bone  parallel  with  the  cleft,  for  its  whole  length, 
including  the  soft  palate.  The  width  of  this  incision 
from  the  margin  of  the  cleft  varies  with  that  of  the 
cleft;  usually  it  approaches  the  teeth.  A  flap  is  now 
dissected  up,  composed  of  all  tissues,  including  peri- 
osteum (care  being  taken  to  draw  out  the  palatine  ves- 


URANOPLASTY. 


173 


sels  and  either  tie  or  twist  them)  to  within  y^  inch 
of  the  cleft  margin.  The  mucous  membrane,  includ- 
ing periosteum,  is  now  split  along  the  opposite  margin 
of  the  cleft  and  is  raised  up  for  ^  of  an  inch;  the 
opposite  flap  is  turned  over,  periosteal  side  out,  and 
tacked  with  catgut  sutures  underneath  the  split  sur- 
face. The  soft  parts  of  the  velum  and  uvula  are  united 
with  catgut  also.  The  dissection  is  facilitated  by  a 
curved  blade,  two  lines  wide  and  two  inches  long,  on  a 
straight  handle.  The  figures  are  intended  to  illustrate. 
A  slender  needle-holder  and  short,  slightly  curved 
needles  are  essential  to  easy  execution  of  these  steps. 


Fig.  45. — Lane's  operation  for 
cleft-palate. 


Fig.  46. — Flaps  sutured. 


Mouse-toothed  tissue-forceps  are  found  of  service  in 
holding  the  flaps. 

Complete  success  may  not  always  be  attained  in  the 
first  operation,  but  the  defects  can  easily  be  corrected  at 
a  second  sitting.  Loss  of  blood  may  follow  careless 
rupture  of  the  palatine  artery,  and  hence  the  raising  of 
the  periosteal  flap  should  be  carefully  done.  The  after- 
treatment  consists  in  frequently  cleaning  the  surface 
with  diluted  peroxid  of  hydrogen. 

The  sutures,  if  not  harmful,  may  be  allowed  to  remain 
until  absorbed,  or  can  be  removed  any  time  after  eight 
days  if  indicated.  ]\Iore  elaborate  operations  are  sug- 
gested for  specially  complicated  clefts. 


1/4 


HARELIP. 


HARELIP. 


Harelip  is  the  most  common  congenital  deformity, 
rivaling  even  clubfoot,  the  two  often,  however,  present- 
ing  in   the   same   individual.     All   forms  of  imperfect 


Fig.  47. — Harelip  in  a  negro,  showing  irregular  single  harelip  (Shepherd). 

development   are  hereditary,  sometimes  directly  so,  at 
others  intermittent — i.  e. ,  skipping  a  generation  or  so. 
Harelip  may  be  regarded  as  single,  double,  and  com- 


FlG.  48. — Operation  for  double  harelip  without  cleft-palate  (Shepherd). 

plicated.  If  the  growth  of  the  bone  in  embryonic  life 
is  arrested,  as  is  that  of  the  soft  parts,  cleft-palate  and 
other  bony  deformities  may  complicate  the  condition. 
In  single  harelip  there  is  no   bony  deficiency  usually, 


CH  EI  LO  PLASTY. 


/3 


and  the  condition  is  described  as  simple,  although  in 
other  instances  the  cleft  may  involve  the  nostril  or  run 
irregularly  across,  causing  a  most  troublesome  deformity 
with  which  to  deal. 

Operative  steps  promise  the  only  hope  of  relief,  and 
should  be  instituted  preferably  about  the  third  month. 
The  operation  is  termed  cheiloplasty.  The  first  step  after 
anesthesia  and  cleansing  the  part  is  to  free  the  margins  of 
the  cleft  well  up  through  the  frenum  and  on  both  sides,  to 
give  easy  approximation.     The  edges  of  the  cleft  should 


Fig.  49. — Double  harelip  with  cleft-palate  and  protruding  intermaxillary  bone. 

be  pared  so  as  to  restore  the  contour  of  the  lip,  and  great 
care  should  be  observed  properly  to  place  the  vermilion 
border  in  constructive  operations.  No  tissue  should  be 
wasted,  and  the  operator  should  patiently  remove  and 
replace  the  sutures  until  a  good  form  results.  All  pos- 
sible tension  should  be  avoided  and  full  allowance  for 
retraction  made.  When  the  premaxillary  bone  projects 
it  should  be  fractured  forcibly,  and  the  sides  freshened 
and  sutured  to  the  fixed  alveolar  border.  It  frequently 
happens  that  a  long  vomer  attaches  to  the  protruding 
bone.      Then   a   subperiosteal   resection  of  a  V-shaped 


lyG 


HARELIP. 


portion  of  the  vomer,  with  base  down,  will  be  necessary 
before  the  protruding  portion  be  replaced.     At  times  it 


Fig.  50. — Double  harelip  1  before  operation). 

may  be  necessary  to  excise  the  protruding  preraaxillary 
bone. 


Fig.  51. — Double  harelip  (after  operation). 

All  sutures  should  pass  through  the  skin  and  perforate 
the  opposite  mucous  membrane,  or  vice  versa.  The 
sutures  should  be  tension  sutures,  two  or  three  of  silk- 


CHEILOPLASTY. 


177 


worm-gut,  with  the  remainder  of  No.  i  plain  catgut,  to 
get  approximation  of  the  mucous  membrane.     The  silk- 


FlG.  52. — Double  harelip  (before  operation)  (original). 

worm-gut   should  be  removed    not  later  than  the  fifth 
day. 

The  after-dressing  consists  in  a  gauze  compress,  cut  to 
fit  the  wound,  and  held  in  place  by  a  long  strip  of  best 


Fig.  53- — Double  harelip  after  resection  of  wedge  of  vomer  and  repair  of 
soft  parts  (original). 


rubber  adhesive  plaster,  applied  so  as  to  take  off  tension 
by  drawing  the  cheeks  together.     It  is  well  to  dress  the 
12 


1/8  HARELIP. 

wound  daily.  After  the  fifth  or  sixth  day  the  gauze 
and  plaster  may  be  discontinued  and  a  zinc  ointment 
applied.  Union  will  almost  always  succeed  if  the  paring 
is  freely  done  and  tension  avoided.  Children  with  hare- 
lip and  cleft-palate  usually  are  poorly  nourished,  and 
must  be  allowed  to  take  food  from  a  spoon  or  by  nursing 
mother  or  by  bottle  during  the  repair.  Cleansing  of  the 
wound  once  daily  with  peroxid  of  hydrogen  is  usually 
all  that  is  required. 

When  harelip  and  cleft-palate  coexist,  the  latter  must 
be  repaired  first,  as  more  room  is  thus  allowed  for  work- 
ing in  the  mouth,  although  both  may  be  done  at  the 
same  sitting  in  less  severe  conditions.  These  photo- 
graphs (Figs.  50,  51,  52,  and  53)  represent  two  cases  of 
double  harelip  with  protruding  intermaxillary  bone  and 
cleft  hard  palate,  operated  on  by  the  author.  The  cleft- 
palate  in  each  case  was  successfully  closed  by  an  obtu- 
rator after  recovery. 

SUMMARY. 

Cleft-palate  should  be  operated  on  early  in  suitable 
cases.  Cases  that  have  been  neglected  to  adult  life 
have  been  often  successfully  treated  with  the  obturator. 
Harelip  is  the  most  common  congenital  deformity.  It 
should  be  operated  on  in  the  first  three  months  of  life. 
If  cleft-palate  complicates,  this  should  be  repaired  first. 
Harelip  pins  are  no  longer  used.  Careful  approxima- 
tion of  the  surfaces,  with  as  little  tension  as  possible, 
by  silkworm-gut  sutures  passed  completely  through 
the  tissues,  reinforced  by  catgut  sutures  where  needed, 
answer  the  best  indications.  Silkworm-gut  suture 
should  be  removed  about  the  fourth  day. 


CHAPTER  XXIV. 

LESIONS  OF   THE   LIPS   AND   TONGUE. 

LESIONS  OF  THE   LIPS. 

Angioma  of  the  lips,  or  nevi,  are  unsightly  tumors, 
consisting  of  dilated  blood-vessels,  veins,  arteries,  or 
capillaries.  A  red,  berry-like  tumor,  beginning  well 
within  the  mucous  border  and  noticed  at  birth,  is  the 


Fig.    54. — Angioma  of   the  upper  lip,  showing  the    condition    before  treat- 
ment (Dandridge). 

usual  origin.  Its  growth  is  usually  slow,  but  in  a  few 
years  constitutes  a  blunt  eversion  of  the  lip,  perhaps  as 
large  as  the  thumb,  sometimes  pulsating,  and  more  or 
less  diminishing  upon  pressure  over  the  vessels.     These 

179 


i8o 


LESIONS    OF    THE    LIPS. 


lesions  are  always  congenital,  though  often  the  patients 
do  not  notice  them  until  months  after  birth.  Angio- 
mata  vary  in  structure,  but  in  this  situation  they  con- 
sist chiefly  of  dilated  veins  and  capillaries,  surrounded 
by  increased  fatty  or  fibrous  tissue.  They  bleed  freely, 
even  dangerously,  if  carelessly  incised.  The  diagnosis 
is  unmistakable. 

Treatment. — In  many  instances  these  tumors  may  be 
safely  and  promptly  removed  by  incision,  and  a  plastic 
operation  repairs  the  defect.  Electrolysis  is  appropriate 
to  the  smaller  growths.     I^igation  is  at  times  suitable. 


Fig.  55. — Angioma  of  the  upper  lip,  showing  the  condition  after  treatment 

(Dandridge). 

The  injection  of  astringents,  and  even  the  use  of  the 
thermocautery,  is  dangerous  in  tumors  of  much  size 
because  of  the  tendency  to  produce  thrombosis. 

epithelioma  is  the  almost  uniform  character  of  ma- 
lignant lesions  of  the  face.  It  is  chiefly  seen  in  the 
male  on  the  lower  lip.  It  may  appear  at  any  time  after 
twenty-five  or  thirty  years,  but  is  most  common  iu  late 


Multiple  Benign  Cystic  Epithelioma  (J.  C.  White). 


TREATMENT    OF    EPITHELIOMA    OF    LIP.  l8l 

life.  The  irritation  from  the  smoker's  hot  pipe-stem 
or  that  of  a  sharp  tooth  is  believed  to  be  the  origin  in 
some  cases.  It  first  appears  as  a  fissure  in  the  mucous 
membrane,  or  occasionally  as  a  warty  growth,  tender, 
and  at  times  ulcerated,  with  darting  pains  and  even  a 
slight  hemorrhagic  discharge.  These  are  the  progres- 
sive symptoms,  to  which  are  added  increasing  pain, 
more  extensive  ulceration,  lymphatic  involvement,  loss 
of  appetite  and  strength,  with  later  cachexia.  Usually 
at  least  six  months  will  elapse  before  existence  of  glan- 
dular involvement  is  presented.  This  is  chiefly  in  the 
submaxillary  region,  but  may  extend  until  the  glands 
of  the  cheek  in  various  situations  become  involved. 

The  diagnosis  includes  the  exclusion  of  simple  ulcera- 
tions that  are  sometimes  tedious  and  chronic,  and  chan- 
cre. In  individuals  past  forty-five  simple  ulcerations 
that  tend  to  resist  ordinary  treatment  should  be  regarded 
as  malignant ;  earlier  in  life  the  absence  of  pain,  exten- 
sion, and  the  non-involvement  of  the  lymphatics  justi- 
fies longer  delay,  although  to  be  cured  excision  must  be 
early. 

Chancre,  while  greatly  resembling  epithelioma,  is 
early  succeeded  by  enlarged  lymphatics  and  the  sec- 
ondary symptoms  of  the  disease ;  moreover,  it  promptly 
responds  to  anti-syphilitic  remedies. 

Tubercular  ulcerations  on  the  lip  are  infrequent  and 
usually  secondary. 

Treatment. — As  elsewhere  suggested,  the  treatment 
of  all  accessible  malignant  disease  consists  in  prompt 
and  thorough  removal.  Epithelioma  of  the  face  is  a 
striking  illustration  of  the  tendency  of  apparently 
benign  growths  to  take  on  malignancy  after  years  of 
quiescence.  Several  }-ears  may  elapse  from  the  dis- 
covery of  the  lesion  before  it  begins  a  destructive 
ulceration.  Besides,  the  tendency  to  recurrence  is  less 
in  this  form  of  carcinomata  than  in  any  other.  In  this 
is  found  great  encouragement  to  prompt  and  thorough 
work.      Not  only  is  free  extirpation  of  the  entire  ulcer 


l82 


LESIONS    OF   THE    LIPS. 


imperative,  but  careful  search  for  enlarged  lymphatics, 
both  in  the  immediate  region  and  all  about  the  jaw 
and  in  the  neck,  is  demanded.  All  such  glands,  both 
deep  and  superficial,  should  be  freely  extirpated.  In 
the  greater  majority  of  epitheliomata  of  the  lip  an  early 
operation  consists  in  the  simple  V-shaped  removal  of  the 


Fig.  56. — Epithelioma  of  the  skin  (Matas). 


ulcer.  This  furnishes  a  greater  percentage  of  cures 
than  any  other  form  of  malignancy,  and  usually,  if 
recurring,  relief  is  experienced  for  five  or  ten  years.  In 
epithelioma,  both  primary  and  recurrent,  and  in  recur- 
rent scirrhus,  repeated  exposure  to  the  Rontgen  rays  has 
seemed  curative.  Time  has  not  yet  elapsed  to  prove 
fully  the  value  of  this  treatment,  but  it  seems  to  promise 


HYPERTROPHY  OF  THE  TONGUE.  1 83 

much  for  inoperable  and  recurrent  malignant  lesions,  as 
well  as  intractable  tubercular  ulcers  and  lupus. 

Cut  wounds  of  lips  and  of  tongue  are  very  common, 
either  from  sharp  instruments  or  from  bruising  against 
the  teeth.  The  inside  of  the  cheek  and  the  lip  and  bor- 
der of  the  tongue  may  suffer  in  a  similar  manner.  A 
foreio-n  body  may  remain  in  such  wounds  within  the 
mouth.  Pain  and  hemorrhage  are  the  immediate  symp- 
toms, the  hemorrhage  often  being  stubborn  and  trouble- 
some, and  if  the  lingual  artery  is  involved,  operative  steps 
may  be  required.  This  is  rare,  however.  Usually 
wounds  on  the  lips  are  carefully  cleaned,  and  the  edges 
accurately  approximated  by  silk  or  horse-hair.  Catgut 
does  not  answer  well,  for  if  cut  short,  it  becomes  untied; 
and  if  left  long,  it  gets  in  the  way.  The  sutures  are 
usually  removed  on  the  fourth  day.  Wounds  of  the 
tongue  commonly  do  not  require  suture,  but  when 
there  is  troublesome  hemorrhage  or  gaping,  the  needle 
should  penetrate  to  the  bottom  of  the  gap  and  close  it 
up  well.  Even  less  frequently  is  suture  required  in 
wounds  within  the  cheek.  All  wounds  within  the 
mouth  tend  to  give  an  odor  to  the  breath.  Mouth- 
washes containing  some  form  of  carbolic  acid,  of  which 
listerin,  camphophenique,  and  many  others  are  examples, 
should  be  employed  frequently  through  the  day;  sloughs 
may  be  removed  with  the  scissors,  as  indicated. 

LESIONS  OF  THE  TONGUE. 

Hypertrophy  of  the  tongue,  or  macroglossia,  is 

congenital — angioma  of  the  tongue.  It  is  very  rare. 
Other  forms  of  hypertrophy,  the  result  of  inherited 
syphilis,  may  be  seen  in  later  childhood.  For  angioma 
of  the  tongue,  amputation  of  the  tip  should  be  done 
as  indicated. 

Syphilis  of  the  Tongue. — Ulcerations  of  the  tongue 
are  always  to  be  regarded  with  suspicion,  and  when  at 
all  chronic,  may  be  set  down  as  syphilis,  tuberculosis, 
or  cancer. 


184  LESIONS    OF    THE    TONGUE. 

Chancre  of  the  tongue  is  comparatively  frequent. 
The  history  as  to  causation  is  not  easily  obtained,  but 
the  early  glandular  involvement  and  the  eruption  will 
usually  indicate  the  trouble.  Upon  suspicion  anti- 
syphilitic  treatmicnt  will  be  of  great  service.  Secondary 
lesions  of  syphilis,  redness  of  the  tongue  and  fissured 
surface,  are  common.  They  require  constitutional  treat- 
ment and  history  for  positive  diagnosis.  Gummata 
appear  later,  in  the  tertiary  form.  Usually  lymphatic 
involvement  is  not  encountered  in  secondary  and  tertiary 
lesions.  Ulcerations  of  broken  gummata  may  invade 
the  hard  palate. 

Treatment  of  all  these  lesions  is  cleanliness,  mouth- 
washes, and  the  exhibition  of  the  specifics  for  the  dis- 
ease, in  the  manner  outlined  elsewhere  in  this  book. 

Tuberculosis  of  the  tongue  usually  is  multiple,  and 
though  somewhat  resembling  syphilitic  ulcerations,  is 
not  attended  with  the  history  of  the  primary  sore,  nor 
the  gummatous  swellings  of  the  tertiary  stage.  The 
ulcers  are  superficial,  perhaps  somewhat  elevated  above 
the  surface, — while  those  of  syphilis  are  excavated, — 
painless,  and  without  infiltration.  The  discharge  is 
slight.  The  germ  may  sometimes  be  found  in  the 
layer  of  false  membrane  that  covers  the  ulcer. 

Treatment. — Like  the  treatment  of  all  superficial  and 
skin  tuberculoses,  free  incision  offers  the  best  prospect. 

Carcinoma  of  Tongue. — The  form  taken  by  cancer 
of  the  tongue  is  epithelioma.  The  affection  is  frequent, 
and  is  believed  to  be  often  caused  by  irritation  of  jagged 
teeth  and  by  pipe  and  cigar  smoke.  The  development 
is  usually  slow,  and  in  earlier  stages  may  be  confounded 
with  syphilitic  and  tubercular  lesions. 

Epithelioma  is  nearly  always  seen  at  or  after  middle 
life.  It  usually  progresses  slowly,  but  unlike  epithelial 
tumors  of  the  lip,  produces  early  lymphatic  involve- 
ment, and  the  disease  is  almost  hopeless,  in  later  stages 
at  least. 

Symptoms. — The  form  is  chiefly  that  of  an  ulcer  with 


DIAGNOSIS    OF    EPITHELIOMA    OF    TONGUE. 


185 


indurated  edges  and  an  offensive  discharge.  The  situa- 
tion is  usually  at  one  edge,  or  perhaps  the  tip.  The 
glands  under  the  jaw  and  at  the  root  of  the  tongue 
become  involved  early  and  swallowing  is  painful.  The 
characteristic  darting  pains  of  carcinoma  are  common; 
cachexia  soon  appears. 

Diagnosis  from  other   ulcers  is  made  by  history  and 


Fig.  57. — Cancer  of  the  left  half  of  the  tongue  and  the  floor  of  the  mouth. 
Rapid  recurrence  after  removal  of  half  of  the  tongue  (Dandridge). 


age  of  patient,  as  well  as  by  trial  of  antisyphilitic  treat- 
ment in  doubtful  cases. 

Treatment  is  early  extirpation.  If  the  growth  is 
limited  to  the  tip,  it  may  be  removed  by  a  wedge-shaped 
incision.  When  the  edges  are  involved,  usually  half  the 
tongue  must  be  sacrificed,  and  in  ulcers  involving  the 
floor  or  surface  of  the  tono-ue  the  entire  orean  must  so. 


1 86  LESIONS    OF    THE    TONGUE. 

Operations  upon  the  tongue  are  to  be  approached  with 
care;  not  alone  is  there  danger  of  very  troublesome 
hemorrhage,  but  septic  pneumonia  often  follows  an 
otherwise  successful  operation.  Careful  preparatory 
treatment,  not  only  of  the  mouth,  but  of  the  teeth  as 
well,  should  precede  all  operations;  and  as  after  re- 
moval of  the  tongue  it  will  be  necessary  to  feed  by  a 
stomach-tube,  the  patient  should  be  accustomed  to  the 
passage  of  the  tube  beforehand.  Extirpation  of  the 
tongue  is  in  every  way  a  dangerous  operation,  only  to 
be  undertaken  by  an  experienced  hand.  (Further 
description  would  be  out  of  place  in  this  book.) 

SUMMARY. 

Angiomafa  of  the  lips  are  vascular  birth-mark  tumors; 
are  seen  on  either  border,  varying  in  size  from  that  of  a 
pea  to  that  of  a  small  ^^-g.  Treatment  consists  in  either 
extirpation  or,  in  small  growths,  electrolysis. 

Epithelioma  is  most  common  on  lower  lip  in  elderly 
smokers,  as  a  warty  growth,  with  later  shooting  pains, 
and  in  a  year  or  so  lymphatics  under  the  jaw  are  in- 
fected.    Early  extirpation  is  imperative. 

Cut  wounds  of  the  lip  heal  readily.  Arteries  should 
be  either  tied  or  compressed  with  suture  or  pin.  The 
vermilion  border  should  be  approximated  with  catgut 
sutures,  not  too  tightly,  and  deeper  skin  and  muscular 
cuts  should  be  united  with  silkworm-gut. 

Chronic  ulcerations  are  syphilitic,  malignant,  or  tuber- 
cular. The  age  and  history  will  help  determine,  and 
treatment  will  help  in  the  diagnosis.  Syphilis  in  the 
third  stage  is  usually  single,  and  with  its  history  will 
exclude  malignancy,  while  tuberculosis  is  multiple. 
Treatment  of  carcino^na  is  extirpation  at  the  earliest 
moment. 


CHAPTER    XXV. 
DISEASES  OF  THE  SALIVARY  GLANDS. 

Infection  and  suppuration  of  the  salivary  glands 

arise  chiefly  in  the  course  of  some  constitutional  fever, 
either  scarlet  or  typhoid.  Chronic  suppurations  are 
almost  always  tubercular,  although  actinomycosis  is 
sometimes  a  cause.  The  gland  chiefly  involved  is  the 
parotid.  This  gland  lies  at  the  angle  of  the  jaw,  in 
front  of  the  ear,  and  does  not  show  in  health.  There  is 
apparently,  but  without  explanation,  much  sympathy 
between  the  parotid  gland  and  exhausting  systemic 
diseases,  for  it  becomes  swollen  and  painful  in  many 
constitutional  conditions  without  suppuration  and  some- 
times reddening  of  the  overlying  skin  presents.  When 
softening  and  suppuration  occur,  the  abscess  should  be 
promptly  opened,  as  sometimes  the  pus  seeks  exit 
through  the  mouth  or  ear  or  burrows  down  into  the 
neck. 

Extensive  involvement  of  adjacent  glands  may  take 
place  in  neglected  infections  of  the  parotid.  The  diag- 
nosis should  be  confirmed  by  the  introduction  of  the 
exploring  needle.  Such  abscesses  should  be  cautiously 
opened  by  dissection  until  the  pus  is  reached,  arid  then 
an  artery  forceps  passed  in  and  the  cut  dilated  until  free 
drainage  is  obtained.  The  situation  of  the  external 
carotid  and  internal  maxillary  artery  in  the  gland  must 
be  remembered,  as  dangerous  hemorrhage  may  ensue  if 
deep  and  careless  incisions  are  made. 

Chronic  suppurations  of  the  parotid  usually  in- 
volve many  other  glands  in  the  tuberculous  process, 
and  the  propriety  of  extirpation  becomes  a  difllicult 
question,  for  unless  all  diseased  tissue  can  be  removed, 

1S7 


1 88  DISEASES    OF    THE    SALIVARY    GLANDS. 

the  expectant  plan  is  best.  Removal  of  the  parotid 
gland  is  too  difficult  an  operation  to  be  justified  unless 
benefit  be  assured. 

Similar  affections  of  the  other  salivary  glands,  notably 
the  sublingual,  are  to  be  treated  in  the  same  way. 
Acute  suppuration  here  is  rare,  but  tubercular  infiltra- 
tion is  perhaps  more  common. 

Adenoma  of  the  salivary  glands  is  perhaps  not 
seen  except  as  sarcoma,  which  is  the  most  common 
tumor  of  these  organs.  Usually  it  grows  rapidly  and 
pushes  in  the  wall  of  the  pharynx  so  as  to  interfere 
with  swallowing,  and  displaces  the  structures  of  the 
cheek  and  neck  externally.  Commonly  these  growths 
give  early  pain  by  involving  the  facial  nerve  in  its 
course  through  the  parotid  gland,  and  facial  paralysis 
may  thus  be  induced.  Ulceration  externally,  and  even 
internally,  may  occur  early. 

The  prognosis  is  highly  unfavorable,  as  the  growth 
is  usually  rapid  and  involves  tissue  that  cannot  be  eradi- 
cated. If  seen  early,  the  parotid  may  be  removed. 
Death  takes  place  from  exhaustion  usually  ;  or  septic 
pneumonia  or  hemorrhage  from  ulceration  of  the  walls 
of  large  vessels  in  the  neck  may  terminate  the  case  at 
any  time. 

Carcinoma  of  the  salivary  glands  is  less  common. 
Like  cancer  elsewhere,  it  is  usually  seen  in  advanced 
life,  and  is  more  often  secondary,  especially  in  the  sub- 
maxillary and  sublingual  glands.  Carcinoma  of  the 
parotid  grows  more  rapidly  than  is  usual  with  that  form 
of  malignancy,  and  adjacent  lymphatic  involvement  is 
early.  Pain  and  paralysis  from  pressure  on  the  facial 
nerve  are  prominent. 

The  diagnosis  is  made  easily  b}'  the  age  of  the  patient 
and  the  general  features  of  the  case. 

The  treatment  is,  if  seen  early,  removal  of  the 
affected  gland.  iVs  before  indicated,  extirpation  of  the 
parotid  is  a  very  trying  operation,  with  only  slight 
promise   in   malignant  diseases.      It  involves  a  pefma- 


SALIVARY    CALCULI. 


189 


nent  destruction  of  the  facial  nerve  and  a  consequent 
paralysis  of  that  side  of  the  face.  Recently  extirpation 
of  the  external  carotid  artery  after  ligation  has  been 
suggested, — and  in  limited  number  of  cases  tried, — 
thus  cutting  off  the  blood-supply  in  carcinoma  of  the 
salivary  glands,  tonsils,  tongue,  and  antrum.  This 
operation,  heroic  though  it  sounds,  is  less  so  than  ex- 
tirpation of  the  parotid  or  tonsil,  and  even  when  more 


Fig.  58. — Parotid  tumor  (Gould). 


radical  steps  are  contemplated,  should  be  the  prelimi- 
nary to  diminish  the  tendency  to  recurrence. 

Salivary  Calculi. — Salivary  calculi  are  most  com- 
monly seen  in  the  submaxillary  or  sublingual  glands 
or  their  ducts,  but  they  are  not  by  any  means  common. 
They  are  usually  seen  in  }'oung  adult  life,  from  twenty 
to  forty  years,  and  are  commonly  due  to  some  foreign 
substance  either  lodged  in  the  duct,  or  perhaps  carried 
up  into  the  gland   during  the  process  of  mastication. 


IQO  DISEASES    OF    THE   SALIVARY    GLANDS. 

Around  these  foreign  bodies  secretions  of  the  gland 
become  crystallized,  and  thus  the  calculus  is  formed. 

The  symptoms  are  pain  and  swelling,  with  great 
tenderness  at  the  side  of  or  beneath  the  tongue,  involv- 
ing the  submaxillary  triangle  and  even  the  base  of  the 
tongue.  The  pain  and  tenderness  are  usually  severe, 
with  elevation  of  temperature  and  a  general  feeling  of 
malaise.  Usually  the  foreign  body  can  be  felt,  espe- 
cially if  it  is  within  the  duct ;  but  if  there  is  much 
swelling,  this  cannot  be  accomplished  unless  the  cal- 
culus is  of  large  size.  The  introduction  of  a  probe  at 
the  orifice  of  the  duct  until  it  encounters  the  calculus 
will  readily  determine  the  diagnosis  when  the  stone  is 
within  the  duct,  and  will  usually  reach  it  if  it  is  in  the 
gland  itself.  If  the  duct  cannot  be  found  or  is  closed 
up  for  any  reason,  exploration  with  a  needle  into  the 
swelling  is  likely  to  encounter  the  calculus,  which  may 
be  diagnosticated  by  the  peculiar  grating  feeling  it 
communicates  through  the  needle.  These  swellings 
are  to  be  differentiated  from  malignant  and  other 
tumors  by  their  acute  history  and  the  evidence  of  in- 
flammation that  accompanies  them. 

Treatment. — Usually  when  the  diagnosis  is  made 
there  is  little  difficulty  in  the  removal  of  the  calculus, 
either  from  the  duct  or  the  gland.  Frequently  a  tem- 
porary salivary  fistula  results,  which  soon  gets  well 
without  treatment.  The  incision  is  preferably  made 
within  the  mouth,  and  only  when  there  have  been  sup- 
puration and  destruction  of  the  surrounding  parts  should 
there  be  any  effort  made  to  reach  the  foreign  body 
through  the  skin,  not  only  on  account  of  the  scar  that 
such  procedure  leaves,  but  also  because  there  is  more 
risk  of  salivary  fistula. 

Salivary  Fistula. — This  lesion  is  even  less  common 
than  calculus.  It  is  occasionally  seen,  however,  after 
extensive  destruction  from  these  foreign  bodies  in  the 
cheek,  and  also  from  traumatism  from  other  causes,  as 


RANULA.  19 1 

well  as  from  operations  for  the  removal  of  malignant 
growths  and  tumors  in  this  situation. 

The  diagnosis  is  easily  made  by  the  presence  of  a 
sinus  through  the  tissues  of  the  neck  or  cheek,  from 
which  the  characteristic  salivary  fluid  is  poured  out. 

The  treatment  of  this  condition  should  be  conducted 
on  the  expectant  plan,  for  a  few  weeks  or  more,  with 
stimulation  by  lunar  caustic.  If  the  fistula  does  not 
close  through  these  measures,  an  incision  should  be 
made  through  the  mucous  membrane,  and  the  cut  sur- 
face of  the  duct  stitched  into  this  wound,  while  the  skin 
is  closed  up  by  suture.     Usually  this  succeeds. 

Ranula. — Ranula  is  a  soft,  fluctuating  tumor  at  the 
surface  or  side  of  the  tongue,  due  to  an  occlusion  of  the 
orifice  of  the  submaxillary  or  sublingual  ducts.  It  is 
a  glossy,  smooth,  painless  tumor,  which  continues  to 
erow  until  it  varies  in  size  from  that  of  a  small  almond 
to  even  that  of  a  hulled  walnut.  Its  annoyance  to  the 
patient  both  in  mastication  and  in  general  use  of  the 
tongue  leads  him  to  seek  treatment.  Ranula  is  quite 
a  common  affection,  seen,  as  in  the  case  of  salivary 
fistula,  in  young  adult  life.  Sometimes  the  constric- 
tion of  the  duct  is  sufficient  only  partially  to  occlude 
it,  and  by  pressure  upon  the  tumor  its  contents  can  be 
made  to  escape  into  the  mouth,  and  the  tumor  disap- 
pears. 

The  tumor  is  to  be  diagnosticated  from  other  lesions 
by  its  situation,  its  smooth,  fluctuating  outline,  the 
absence  of  pain  and  tenderness,  and  usually  the  history 
of  recent  gradual  development. 

Treatment. — This  is  by  no  means  satisfactory,  inas- 
much as  there  is  a  constant  tendency  to  recurrence. 
The  simplest  treatment  is  the  best,  which  consists  in 
passing  a  seton  of  coarse  thread  through  the  base  of  the 
tumor,  taking  pains  to  keep  up  the  ulceration  thus 
established  until  a  permanent  opening  is  made  through 
which  the  contents  of  its  duct  can  escape  into  the 
mouth.       When    these    measures    do    not    prevent    the 


192  DISEASES    OF    THE   SALIVARY    GLANDS. 

redevelopment  of    the    tumor,   extirpation  of   the    cyst 
and  the  gland  is  to  be  emplo^'ed. 

SUMMARY. 

Abscess  of  the  parotid  gland  occurs  occasionally  in 
typhoid  and  scarlet  fever.  Abscess  should  be  promptly 
opened  by  cautious  dissection,  as  important  vessels  are 
in  close  proximity.  Extirpation  of  the  parotid  is  very 
difficult  and  dangerous. 

Malig7iant  growths  of  the  parotid  are  not  common ; 
they  grow  rapidly.  If  the  growth  cannot  be  extirpated, 
ligation  and  extirpation  of  the  external  carotid,  or  liga- 
tion of  the  common  carotid,  are  recommended. 

Salivary  calculi  cause  pain,  swelling,  and  great  ten- 
derness underneath  the  tongue ;  often  the  calculus  can 
be  felt  by  the  fingers.  It  can  be  located  by  passing  a 
probe  into  the  duct,  if  it  is  open.  Usually  the  stone 
can  be  removed  through  the  mouth. 

Salivary  fistula  is  indicated  by  a  sinus  through  the 
neck  or  cheek,  discharging  salivary  fluid.  Usually  they 
heal  without  operation,  but  at  times  incision  and  suture 
are  required. 

Ramila  is  a  tumor  under  the  tongue ;  its  contents 
are  clear  mucus.  Treatment  is  unsatisfactory.  Extir- 
pation is  to  be  done  when  other  measures  fail. 


CHAPTER  XXVI. 

DISEASES  OF  THE  MAXILLARY  AND  OTHER  SI= 
NU5ES.— EMPYEMA  OF  THE  ANTRUM.— CYSTS 
AND  POLYPI ACROMEGALY. 

Diseases  of  the  Maxillary  Sinuses. — When  it  is 
remembered  that  the  mucous  membrane — the  so-called 
Schneiderian — of  the  nose  communicates  through  fora- 
men and  passages  with  the  antrum  of  Highmore  or 
maxillary  sinus,  as  well  as  with  the  frontal  and  ethmoid 
cavities,  it  will  be  seen  that  important  and  even  vital 
structures  may  be  involved  by  the  extent  of  septic  in- 
flammation, the  outer  air  thus  communicating  with  cavi- 
ties in  close  proximity  to  the  brain.  The  antrum  of  High- 
more  is  located  in  the  superior  maxilla,  with  the  orbital 
floor  as  its  roof  It  communicates  with  the  correspond- 
ing middle  meatus  of  the  nasal  cavity  by  a  short  canal 
at  its  base.  There  is  not  very  free  communication  in 
health  between  these  two  cavities,  as  forcible  distention 
with  air  is  often  required  to  open  freely  the  mucous 
membrane  that  lines  the  foramen.  The  cavity  of  the 
antrum  is  irregular  on  all  its  surfaces ;  its  walls  are  thin 
and  easily  displaced  by  the  pressure  of  fluids,  and  solid 
growths  push  the  orbital  floor  up  and  displace  the  eye- 
ball. The  frontal  sinus  on  the  corresponding  side  com- 
municates with  the  antrum  through  the  nasal  passage, 
and  when  the  frontal  sinus  is  overdistended  with  fluids, 
purulent  or  otherwise,  it  is  claimed  a  direct  passage  into 
the  antrum  is  often  effected.  The  ethmoid  aud  frontal 
sinuses  thus  drain  freely  into  the  nasal  passage,  and 
accumulations  are  not  only  less  rare,  but  the  tendency 
to  auto-infection  is  removed,  while  in  the  antrum  satis- 
factory drainage  by  nature  is  not  possible,  and  infection 

13  193 


194      DISEASES    OF    MAXILLARY    AND    OTHER    SINUSES,    ETC. 

progresses  readily.  Inflammatory  and  suppurative  ac- 
cumulations within  the  antrum,  if  not  relieved,  may 
force  their  way  into  the  orbit,  or  internally  into  the 
nose  or  mouth.  This  discharge  may  run  back  into  the 
fauces  during  sleep  and  produce  nausea  and  vomiting 
of  a  most  distressing  character. 

Diseases  of  the  maxillary  sinus  have  become  a  field 
for  the  dental  surgeon.  The  forms  of  lesion  which  in- 
terest him  chiefly  are :  i.  Traumatism  from  extraction 
of  teeth.  2.  Acute  infections  through  the  nose.  3. 
Tumors.     4.   Disease  of  the  bone. 

When,  as  often  happens,  the  roots  of  the  teeth  run 
up  under  the  antrum  and  penetrate  almost  into  that 
cavity, — and  at  times  a  root  or  even  a  whole  tooth  may 
become  loosened  and  fall  into  the  cavity, — disease  of 
these  roots  often  sets  up  the  infection.  Accidents  in 
extraction  may  also  break  into  and  infect  the  cavity. 
Fractures  externally  and  bullet  or  penetrating  stab 
wounds  may  account  for  the  lesion.  The  results  of 
such  cases  are  pain,  swelling,  and,  if  not  property  treated, 
suppuration^  but  usually  such  conditions  declare  them- 
selves and  are  promptly  treated.  In  one  case  coming 
under  the  observation  of  the  author  a  blow  from  a  base- 
ball permanently  depressed  the  anterior  antral  wall, 
with  recovery  only  after  a  troublesome  suppurative 
inflammation. 

By  far  the  most  common  cause  of  trouble  in  the  sinus 
is  acute  inflammation,  with  more  or  less  suppuration. 
The  cause  is  the  admission  of  germs  from  without 
through  the  nasal  communication.  Influenza  is  believed 
to  be  a  most  potent  factor,  and,  indeed,  antritis  is  one  of 
its  symptoms.  Any  pyogenic  infection  of  the  nose  is 
prone  to  extend  to  the  antrum. 

Symptoms. — Whatever  the  cause,  inflammation  of 
the  antrum  produces  the  same  character  of  symptoms: 
neuralgic  pain  in  the  side  of  the  face,  tenderness  on 
pressure,  swelling  and  often  redness  of  the  skin  over  the 
sinus,   offensive   breath,   and    discharge    from  the  nose, 


CYSTS    AND    POLYPI.  I95 

especially  on   forcible   snuffing  np.     Chilly  sensations, 
rigors,  fever,  and  general  malaise  are  present. 

Transillumination  with  an  electric  bulb  in  the  mouth 
ascertains  whether  the  cavity  is  transparent  ;  and  if 
opaque,  that  some  solid  contents  are  inclosed.  It  does 
not,  however,  declare  the  nature  of  the  obstruction. 
Nausea  and  offensive  discharge  are  present  often  in 
severer  forms. 

Diagnosis. — In  abscess  the  symptoms  are  acute,  fever 
is  often  present,  and  the  discharge  is  usually  seen  in  the 
sputum,  and  often  from  the  nasal  canal. 

Cysts  and  polypi,  as  well  as  other  tumors,  grow 
slowly,  cause  little  pain  in  the  early  stage,  and  present  a 
history  of  comparatively  long  standing. 

Treatment. — In  the  milder  forms  of  infection  hot 
applications,  with  some  sedative,  purgation,  quinin,  and 
extract  of  belladonna  are  of  service.  In  neuralgic  pain, 
prior  to  suppuration,  antikamnia  has  given  relief  in  the 
author's  hands.  When  protracted  suppuration  occurs, 
drainage  is  indicated.  If  the  cause  is  a  damaged  tooth, 
this  should  be  extracted,  and  a  perforation  made  through 
the  socket  into  the  antrum.  When  the  teeth  are  .sound,  it 
is  better  to  push  a  trocar  through  the  wall  of  the  antrum 
just  above  the  root  of  the  second  bicuspid,  taking  care 
that  the  trocar  is  not  forced  through  the  posterior  or 
opposite  wall  of  the  antrum.  The  mucous  membrane 
should  first  be  incised  and  the  trocar  forced  through,  and 
free  drainage  made.  If  with  antiseptic  irrigation  the 
discharge  does  not  soon  cease,  it  is  well  to  curet  the 
antrum,  and  if  disease  of  the  bone  be  suspected,  it 
should  be  explored  for.  When  chronic  suppurative  dis- 
ease of  the  nasal  canal  coexists  with  antral  abscess^ 
drainage  through  the  nose,  with  curetment  and  irriga- 
tion with  boric  acid  solutions  should  be  employed. 

It  is  claimed  that  over  half  of  all  cases  of  chronic 
antral  disease  have  a  complication  in  nasal  polypi,  and 
very  often  polypi  in  the  antrum  itself.  They  may  exist 
for  years  without  noticeable  symptoms.    Their  existence 


196      DISEASES    OF    MAXILLARY    AND    OTHER    SINUSES,    ETC. 

is  to  be  suspected  if  nasal  polypi  exist  with  antral  symp- 
toms. Mucous  cysts  and  polypoid  growths  occupying 
the  antrum  are  reached  by  exploration  above  the  second 
bicuspid.  An  opening  is  made  which  will  admit  the 
little  finger,  and  the  lesion  removed  by  the  curet.  After- 
ward irrigation  should  be  employed,  and  the  wound 
packed  with  gauze.  Such  exploration  bleeds  freely,  and 
may  require  a  tight  packing.  On  removal  after  twenty- 
four  hours  and  the  repetition  of  the  irrigation  the  pack- 
ing may  be  more  loosely  replaced. 

Of  the  other  tumors  of  the  antrum,  the  bony  growths 
are  likely  to  be  sarcoma,  or  rarely  carcinoma,  and 
require  extensive  surgery  for  their  removal,  as  they  are 
usually  not  early  presented  for  treatment.  The  growth 
of  malignant  tumors  of  the  antrum  is  usually  rapid,  and 
great  deformity  soon  presents,  though  perhaps  in  the 
earlier  stages  there  is  little  pain.  Involvement  of  the 
lymphatic  glands  of  the  neck  and  jaw,  while  not  early, 
usually  becomes  a  symptom  in  malignant  growths. 
Bony  growths  and  cysts  can  be  distinguished  from  ma- 
lignant by  exploration  and  the  history. 

Treatment.— Bony  growths  without  malignant  symp- 
toms should  be  allowed  to  remain  unless  they  are  in  the 
early  stages.  Cysts  should  be  cureted,  washed  out,  and 
packed  or  treated  as  indicated. 

In  malignant  growths  of  the  antrum  and  superior 
maxillary  bone  the  prognosis  is  most  unpromising.  If 
seen  early,  the  superior  maxillary  should  be  fully  re- 
moved.    This,  however,  is  not  a  promising  operation. 

Bone  disease,  as  has  already  been  said,  indicates  the 
removal  of  all  diseased  bone  with  the  gouge.  It  is 
claimed  that  ligation  and  excision  of  the  external  carotid 
artery  starves  the  growth  in  malignant  disease  of  the 
antrum,  even  after  the  tumor  has  become  inoperable. 
Such  a  step  should  always  be  a  part  of  the  operation  for 
removal  of  the  superior  maxilla  for  malignancy. 

Acromegaly. — By  this  term  is  described  a  rare  form 
of  hypertrophy  of  the  bones  of  the  skeleton,  giving  a 


ACROMEGALY.  197 

giant  shape  especially  to  the  feet,  face,  and  hands.  All 
the  bones  of  the  skeleton  participate  in  the  enlargement. 
Usually  it  is  first  noticed  in  the  hands;  later  on  the  soft 
parts  covering  the  bones  are  thickened  and  hypertro- 
phied.  Usually  the  condition  is  seen  in  young  adults, 
and  progressively  increases.  The  pathology  is  unknown. 
Physical  weakness  and  impaired  sensation  attend  later, 


Fig.  59. — Leontiasis  ossea  (cast  in  Warren  Museum). 

and  the  patient  usually  succumbs  in  a  few  years  to  some 
intercurrent  affection.  The  inferior  maxilla  often  be- 
comes enormously  enlarged,  although  the  appearance  is 
not  so  much  a  deformity  as  a  striking  feature.  The 
same  applies  to  the  enlargement  of  the  feet  and  hands. 

No  especial  treatment  has  seemed  to  be  of  any  service. 

A  similar  form  of  hypertrophy  which  is  limited  to  the 
bones   of  the    face    and    skull  is  termed   leojitiasis^   the 


198       DISEASES    OF    MAXILLARY    AND    OTHER    SINUSES,    ETC. 

facial  skeleton  having  a  fancied  resemblance  to  that  of  a 
lion.  The  hypertrophy  is  symmetric,  and  progresses  in 
the  direction  of  the  cavities,  as  well  as  the  outer  sur- 
faces. Thus  the  eyeballs  are  pushed  out  of  the  sockets, 
and  the  nasal  passages,  as  well  as  the  cranial  cavity, 
diminished  in  caliber.  The  progress  of  the  malady  is 
very  slow,  and,  like  acromegaly,  is  usually  accompanied 
by  evidences  of  sympathy  in  the  general  constitution. 
After  many  years  progressive  exhaustion  leaves  the 
victim  to  succumb  to  some  intercurrent  disease. 


CHx\PTER   XXVII. 
NEURALGIA. 

By  neuralsfia  is  meant  functional  disturbance  of  a 
nerve,  with  paroxysmal  pain.  No  appearance  of  dis- 
ease can  be  detected,  and  the  pain  is  to  be  regarded  as 
a  symptom  of  an  irritation  not  located.  Inflammatory 
changes  called  neuritis  may  exist  with  neuralgia,  but 
not  necessarily  so,  and  when  present,  usually  soon  sub- 
side, although  the  paroxysmal  neuralgia  remains. 

Neuralgia  is  caused  by  depressed  conditions  of  the 
system  and  impoverished  blood,  notably  by  malaria 
and  rheumatism,  as  well  as  by  syphilis.  Frequently 
tumors  and  other  forms  of  pressure  produce  the  pain. 
Neuraloia    is    more    common    in    the  middle  and   later 

o 

periods  of  life,  and  more  frequently  seen  in  women  than 
in  men. 

Sytnptoms. — The  pain  is  usually  not  constant.  The 
beginning  is  abrupt,  and  when  due  to  malaria  or  rheu- 
matism, may  be  periodic.  Attacks  may  last  a  few  days 
or  a  week  and  then  pass  away,  and  recur  in  weeks  or 
months.  More  or  less  tenderness,  and  perhaps  even 
swelling,  is  always  present  in  the  protracted  form, 
although  the  paroxysms  may  be  intermittent.  The 
points  of  tenderness  will  indicate  the  situation  of  the 
nerve  that  is  causing  the  pain.  In  the  severe  form  of 
facial  neuralgia,  known  as  tic  doidoitreiix^  there  are 
twitching  of  the  muscles  of  the  face  and  painful  spasm 
of  an  agonizing  character. 

As  dentists  we  are  chiefly  concerned  with  neuralgia 
of  the  trifacial  or  fifth  pair  of  cranial  nerves.  These 
nerves  run  from  the  Gasserian  ganglion  on  the  petrous 
portion  of  the  temporal  bones  in  three  branches — first. 


200  NEURALGIA. 

second,  and  third.  The  ophthalmic  or  first  division 
passes  out  through  the  sphenoid  fissure,  after  which  its 
frontal  branch  becomes  the  point  of  interest.  This 
branch  emerges  from  the  orbital  cavity  at  the  supra- 
orbital notch,  and  is  distributed  above  the  eye.  This 
branch  is  not  often  severely  affected.  Tenderness  at 
the  point  of  exit,  as  well  as  over  the  forehead,  will 
indicate  the  seat  of  trouble.  The  ordinary  medical 
treatment  of  neuralgia  will  usually  control  it  in  this 
situation.  Quinin,  arsenic,  antikamnia,  warmth,  blis- 
ters, general  tonics,  and  opiates  as  indicated  is  the  gen- 
eral outline  suggested.  Salicylates  are  of  service  in 
the  rheumatic  form.  It  is  dangerous  to  continue  too 
long  the  administration  of  morphin  lest  the  habit  be- 
come established.  Croton-chloral  or  the  tincture  of 
gelsemium  sometimes  answers  well  in  controlling  the 
pain.  In  acute  neuralgias  the  author  has  found  a  dis- 
tinctly curative  value  in  the  triturate  of  aconitia,  in  ^^-^ 
to  yI-q-  grain  doses  four  times  daily  until  numbness  of 
the  tongue  results.  If  in  spite  of  these  measures  the  pain 
and  spasm  of  muscles  continue  as  a  chronic  condition, 
removal  of  the  nerve  is  to  be  recommended. 

An  incision  parallel  to  the  eyebrow,  over  the  supra- 
orbital notch,  will  expose  the  nerve  at  its  exit,  when  it 
should  be  twisted  out  (avulsion).  If  necessary,  the 
notch  or  foramen  should  first  be  chiseled  out,  so  as  to 
permit  full  removal  of  the  nerve. 

The  superior  maxillary,  or  second  division  of  the  tri- 
facial, emerges  from  the  foramen  rotundum,  and,  giving 
off  three  branches  to  the  teeth  as  it  passes  across  the 
sphenomaxillary  fossa  and  the  floor  of  the  orbit,  emerges 
at  the  infra-orbital  foramen,  and  spreads  out  between 
the  eye  and  the  angle  of  the  mouth.  In  this  branch  is 
seen  the  most  dreadful  form  of  neuralgia — //c  douloureux. 
In  severe  cases  the  pain  is  hardly  ever  absent,  and  the 
least  movement — attempts  at  talking,  eating,  or  laugh- 
ing— is  sufficient  to  cause  painful  spasm  of  the  muscles 
with  the  most  excruciating  agony.     Life  becomes  almost 


SYMPTOMS  OF  NEURALGIA.  20I 

insupportable  to  the  unhappy  patient,  and  appeals  for 
relief  are  imperative.  Even  morphin  fails  to  give  com- 
fort ;  hunger  and  emaciation  follow  imperfect  digestion 
and  mastication  of  food. 

The  operative  treatment  in  this  branch  should  be 
primarily  the  removal,  as  far  as  possible,  of  the  nerve 
through  the  infra-orbital  canal ;  if  possible,  back  to  the 
foramen  rotundum.  The  steps  are  exposure  of  the 
infra-orbital  canal  by  a  free  incision,  transversely, 
grasping  the  nerve  when  freed  by  artery  clamps.  The 
periosteum  of  the  orbital  plate  is  freed  at  the  margin 
of  the  orbit,  and  with  a  retractor  the  eyeball  lifted  up. 
The  foramen  and  the  infra-orbital  canal  are  now  opened 
with  a  small  chisel  or  a  delicate  bone  forceps  (even  a 
strong  grooved  director  will  sometimes  do),  and  the 
nerve  drawn  out  as  far  as  possible  and  twisted  off. 

Other  operations,  more  difficult  and  mutilating,  pro- 
ceed through  the  walls  of  the  antrum  and  sphenomax- 
illarv  fossa  to  the  sphenoid  bone,  and  cut  off'  the  nerve 
at  this  point.  It  is  the  advice  of  good  surgeons  to  do 
first  the  avulsion  operation  through  the  orbit,  and  if  the 
disease  returns,  to  attempt  more  radical  steps.  These 
operations  usually ,  give  relief  for  from  six  months-  to 
two  years.  If  after  this  there  is  a  severe  return,  removal 
of  the  Gasserian  ganglion  is  to  be  advised.  This  is 
perhaps  best  done  after  a  modification  of  the  method 
of  Hartley.  This  consists  in  making  a  horseshoe  inci- 
sion through  the  scalp  from  the  zygoma,  between  the 
external  angular  process  of  the  superior  maxilla  and 
the  tragus  of  the  ear,  exposing  the  bone  and  making 
an  osteoplastic  resection,  turning  down  the  flap,  and 
breaking:  the  lower  border  at  the  zvgoma.  Then  the 
dura  is  loosened  at  the  foramen,  the  branches  cut  off, 
and  traction  made  on  the  stumps  until  the  ganglion  is 
drawn  out  of  its  bed.  This  operation  has  a  high  mor- 
tality, and  requires  great  skill  and  courage  for  its  per- 
formance. It  yields  the  most  protracted,  and  often  gives 
permanent,  relief     The  dangers  are  from  hemorrhage, 


202 


NEURALGIA. 


meningitis,  and  also  from  sloughing  of  the  eye  from 
impaired  nutrition.  The  author  believes  this  operation 
should  be  the  one  recommended  for  recurrent  neuralgias 
of  the  second  division  if  unrelieved  by  simpler  steps. 

The  inferior  dental,  or  third  division,  emerges  at  the 
foramen  ovale,  and  supplies  the  gums  of  the  teeth  of 


Fig.  6o.  —Operation  on  second  division,  fifth  nerve,  in  sphenomaxillary  fossa; 
temporal  muscle  drawn  backward  (Richardson). 

the  lower  jaw  by  two  branches.  The  inferior  passes 
between  the  internal  lateral  ligament  and  the  ramus, 
and  enters  the  dental  foramen  along  with  the  inferior 
dental  artery.  The  nerves  lie  in  a  canal  in  the  hori- 
zontal ramus  and  emerge  at  the  mental  foramen  to 
supply  the  chin  and  lips. 


SUMMARY.  203 

This  branch  is  quite  frequently  the  seat  of  trouble- 
some neuralgia.  Operative  steps  are  usually  trephin- 
ing the  ascending  ramus  an  inch  and  a  half  above  the 
angle,  and  exposing  the  nerve  high  up.  It  may  then 
be  drawn  out,  and  traction  will  usually  remove  the 
distal  portion  from  the  canal  and  the  jaw.  If  the  infe- 
rior dental  artery  be  divided,  pressure  will  usually  stop 
the  bleeding;  if  not,  ligation  will  be  needed.  Other 
steps  more  complicated  have  been  described  for  remov- 
ing the  nerve. 

SUMMARY. 

Neuralgia  of  the  nerves  of  the  face  as  a  chronic  con- 
dition affects  the  trifacial  nerve.  If  such  conditions 
do  not  respond  to  antiperiodics,  general  tonics,  etc., 
operative  measures  may  be  required.  Removal  of  the 
terminal  filaments  within  the  bony  canal  gives  relief  in 
most  cases  for  a  year  or  so.  If  the  pain  returns  and  is 
violent,  removal  of  the  Gasserian  ganglion  within  the 
skull  should  be  suggested.  The  operation  has  a  high 
mortality,  and  is  to  be  recommended  only  as  a  last 
resort. 


CHAPTER  XXVIII. 

DISLOCATIONS,  WITH  SPECIAL  REFERENCE  TO 
THE  INFERIOR  MAXILLA.— ANKYLOSIS  OF  THE 
LOWER  JAW. 

DISLOCATIONS. 

By  the  term  dislocation  or  luxation  is  meant  a 
slipping  out  of  place  of  movable  articulations. 

We  regard  a  simple  dislocation  one  in  which  no 
notable  complication  is  present. 

A  compound  dislocation  is  an  open  one — one  with  a 
wound  communicating  externally. 

In  complicated  dislocations,  fracture,  extensive  lacera- 
tion of  soft  parts,  rupture  of  large  blood-vessels,  etc., 
may  be  part  of  the  lesion. 

Complete  and  incornplete^  recent  and  old^  are  applied 
to  dislocations,  as  the  terms  indicate.  Some  dislocations 
become  old  earlier  than  others :  in  the  lower  jaw  the 
luxation  is  regarded  as  old  after  three  or  four  weeks. 

By  pri7niiive  is  meant  that  the  bones  remain  where 
first  displaced.  A  later  accident  or  disease  which  pro- 
duces gradual  muscular  contraction  may  alter  the  posi- 
tion' and  produce  a  consecutive  dislocation. 

Co7ige7iital^  recurrent^  spo7itaneous^  traumatic^  bilat- 
eral^ single^  and  double  explain  themselves.  In  the 
naming  of  dislocations  the  distal  bone  entering  into  the 
joint  is  said  to  be  the  dislocated  one. 

The  causes  of  dislocation  are  muscular  contractions, 
occasionally  alone,  but  usuallv  in  collusion  with  ex- 
ternal mechanical  violence.  Muscular  relaxation  and 
previous  displacement  predispose  to  dislocation. 

The  pathology  of  a  dislocation  should  be  clearly  under- 

204 


DISLOCATIONS    OF    THE    LOWER    JAW.  205 

stood.  Always  in  complete  dislocation  there  is  some 
rent  of  the  ligaments. 

When  a  capsule  exists,  it  is  torn  through.  Ligaments 
stretch  only  under  often-repeated  and  long-continued 
tension.  Nerves,  blood-vessels,  tendons,  and  muscles 
are  torn  and  bruised  and  margins  of  the  bony  wall  of 
the  joint  may  be  broken. 

The  prognosis  after  replacement  of  the  dislocation  is 
usually  favorable,  and  perfect  function  is  restored. 
However,  particularly  in  the  old,  chronic  rheumatic 
pains,  atrophy,  and  paralysis  are  among  occasional  se- 
quences. Even  when  the  dislocation  is  not  reduced, 
good  functional  results  are  often  obtained. 

The  symptoms  of  dislocation  are  deformity,  inter- 
ference with  motion,  and  loss  of  power  and  function. 
Besides  these  pain,  swelling,  and  great  distress  present 
in  a  few  hours. 

The  treatment  consists  in  replacing  the  displaced 
bones  as  soon  as  the  diagnosis  is  made.  Usually  an 
anesthetic  is  employed,  and  extension  and  counterexten- 
sion  with  manipulation  will  effect  restoration.  When 
tendons  or  ligaments  interfere  to  prevent  reduction,  in- 
cision and  direct  manipulation  may  be  called  for.  In 
old  dislocations  the  danger  of  too  violent  efforts  at  re- 
duction must  be  kept  in  mind.  Here  arthrotomy  and 
excision  may  be  indicated.  After  reduction  support 
with  the  bandage,  usually  for  a  few  weeks,  is  all  that  is 
required.  Compound  dislocations  after  replacement  re- 
quire treatment  on  the  plan  indicated  in  compound 
fracture.     Amputation  is  sometimes  the  best  course. 

Dislocations  of  the  I/Ower  Jaw. — The  dislocation 
of  special  interest  to  the  dentist  is  that  of  the  lower  jaw. 
This  accident  is,  without  very  satisfactory  explanation, 
much  more  common  in  women  than  in  men;  it  is  seen 
chiefly  in  young  adults,  and  is  one  of  the  most  frequent 
dislocations.  It  is  not  uncommon  to  find  the  incom- 
plete form  as  a  chronic  relaxed  condition  of  the  liga- 
ments, noticed  under  the  heading  of  subliixaiiou.      The 


2o6 


DISLOCATIONS. 


complete  form  is  both  unilateral  and  bilateral,  but  when 
uncomplicated  by  fracture,  is  always  forward,  because 
of  the  contour  of  the  skull. 

In  this  joint  there  is  an  interarticular  fibrocartilage, 
with  a  double  synovial  sac  :  one  between  the  condyle  and 
cartilage  and  one  between  the  cartilage  and  bottom  of 
the  glenoid  cavity.  The  capsular  ligament  partially 
surrounds  the  neck  of  the  bone,  and  two  lateral  liga- 
ments, internal  and  external,  hold  it  up  against  the 
skull.     The  temporal  and  masseter  muscles,  practically 


y 


Fig.  6i. — Bilateral  dislocation  of 
the  jaw  (Makins). 


Fig.  62. — Mode  of  manual  reduc- 
tion (Makins). 


opposing  each  other,  serve  to  maintain  the  position  of 
the  condyle.  The  socket  in  which  the  condyle  rests  is 
quite  a  notch,  and  except  for  the  great  leverage  allowed 
by  the  shape  and  function  of  the  jaw,  would  be  almost 
safe  against  displacement. 

Causes. — These  are  nearly  always  muscular  contrac- 
tions acting  often  over  some  foreign  body  between  the 
teeth.  Attempts  to  bite  large  apples  or  oranges,  yawn- 
ing, or  widely  opening  the  mouth  for  any  reason  are  the 
usual  causes.  Blows  on  the  chin  or  side  of  the  cheek 
from  behind   sometimes  cause    luxation.     Attempts   at 


y^ 


SYMPTOMS — PROGNOSIS — TREATMENT.  20/ 

extraction  of  the  teeth  in  rare  instances  dislocate,  as 
they  sometimes  fractnre,  a  jaw. 

The  symptoms  of  dislocation  of  the  lower  jaw  are 
almost  unmistakable.  When  the  dislocation  is  bilateral 
the  chin  is  thrust  forward,  the  mouth  is  partly  open  and 
cannot  be  closed.  When  unilateral,  the  line  of  the 
teeth  is  interrupted,  and  the  chin  one-sided.  Saliva 
dribbles  from  the  mouth.  The  condyle  can  be  felt  and 
usually  seen  in  the  temple,  while  the  depression  left  by 
the  escaped  condyle  can  be  made  out  with  the  finger. 
The  stretched  tendon  of  the  temporal  muscle  can  be  seen 
and  felt  above  the  cavity,  carried  forward  by  the  coro- 
noid  process. 

As  most  of  these  symptoms  are  always  present,  the 
diagnosis  is  very  easy. 

Prognosis. — Many  recurrent  dislocations  of  the  lower 
jaw  are  encountered,  and  it  is  to  be  remembered  that 
the  lesion  is  prone  to  recur,  even  after  perfect  restora- 
tion. Replacement  in  the  recent  form  is  easy,  but  after 
three  or  four  weeks  adhesions  take  place  about  the  head 
of  the  bone,  and  in  many  instances  make  it  almost  im- 
possible to  restore  the  bone  without  resort  to  arthrot- 
omy. 

Treatment. — The  simplest  and  most  common  method 
consists  in  introducing  the  thumbs,  previously  wrapped 
with  bandages  for  protection,  well  back  on  the  molar 
teeth,  and  then  pressing  downward  on  the  angle  of  the 
jaw  with  the  thumbs,  while  the  fingers  lift  up  the  chin, 
thus  disengaging  the  condyle  and  permitting  it  to  return 
to  the  glenoid  cavity.  This  step  is  usually  accom- 
plished without  anesthesia,  but  where  it  is  not  success- 
ful, it  is  better  to  relax  the  muscles  with  chloroform 
and  repeat  the  manipulations.  In  the  rare  instances 
when  this  fails,  wedges  of  cork  may  be  put  well  back 
on  the  displaced  side  or  sides  and  then  used  as  levers, 
while  pressure  backward  and  downward  is  made  on 
the  coronoid  process.  In  old  dislocations  not  yielding 
readily  arthrotomv  is  to  be  employed. 


208  ANKYLOSIS    OF    THE    LOWER    JAW. 

After  reduction  the  joint  should  be  held  in  place  for 
a  couple  of  weeks  with  a  Barton  bandage,  and  the 
patient  fed  on  a  liquid  diet. 

Subluxation  of  the  jaw  is  seen  in  individuals  of. 
relaxed  constitutional  vigor,  often  young  women.  It  is 
indicated  by  a  clicking,  of  the  bone  against  the  socket 
in  eating  and  talking.  Often  this  is^  very  annoying. 
Considerable  latitude  of  motion  is  sometimes  permitted. 
The  lesion  is  not  one  of  great  importance,  and  usually 
gets  well  under  tonics  and  massasfe. 

ANKYLOSIS  OF  THE   LOWER  JAW. 

By  ankylosis  of  the  temporomaxillary  joint  is  meant 
an  interference,  more  or  less  complete,  with  the  func- 
tions of  the  joint,  limiting  the  ability  to  open  the 
mouth  from  partial  interruption  to  almost  absolute 
fixation. 

Ankylosis,  besides  being  partial  and  complete,  is  tem- 
porary (or  false)  and  pej^manejit — usually  bony  or  true 
ankylosis. 

Temporary  or  false  ankylosis  is  due  to  conditions 
outside  the  articulation.  It  is  quite  a  common  thing 
for  the  irritation  caused  by  the  eruption  of  a  wisdom- 
tooth  greatly  to  interfere  with  movement  of  the  jaw, 
partly  from  pain  and  muscular  spasm,  and  partly  from 
swelling  of  the  tissues.  Severe  tonsillitis  often  greatly 
limits  movement. 

The  symptoms  are  usually  clear,  and  in  a  short  time, 
with  such  treatment  as  the  tooth  indicates,  will  pass 
away.  When,  however,  from  persistent  irritation,  or 
from  tubercular  disease  of  the  glands  about  this  region, 
or  from  abscess  seated  in  the  cellular  tissue  or  even  the 
masseter  muscle  itself,  or  from  disease  involving  the 
periosteum  and  bone,  there  is  established  a  chronic 
inflammatory  infection  of  the  fascia  and  structures  gen- 
erally in  this  region,  a  more  serious  and  persisting  ob- 
struction to  function  is  encountered. 

The  symptoms  of  such  infection  are  the  swelling  and 


TREATMENT  OF  TEMPORARY  OR  FALSE  ANKYLOSIS.  2O9 

pain  on  movement,  with  the  ordinary  indications  of 
suppuration  if  pus  exists.  Sometimes  the  mouth  can 
be  only  half  opened,  or  even  less.  In  long-persisting 
inflammations  adhesions  of  a  very  troublesome  nature 
may  form. 

Syphilitic  and  tubercular  lesions,  as  well  as  trauma- 
tism, may  leave,  after  apparent  recovery,  bands  and 
cicatricial  contractions,  both  within  the  mouth  and  in 


Fig.  63. — Operation  in  front  of  cicatrix,  opening  but  one-half  of  the  mouth 
and  leaving  cicatrix  (Mears). 

interstitial  deposits,  which  occasion  long-persisting  and 
even  permanent  obstruction. 

Treatment. — When  the  false  ankylosis  is  due  to  tooth 
eruption,  either  removal  of  the  tooth  or  such  scarifica- 
tion of  the  covering  mucous  membrane  as  will  free  it, 
are  the  indications.  When  chronic  inflammations  of 
specific  character  are  present,  w^armth,  protection,  and 
appropriate  local  and  constitutional  treatment  should 
be  employed.  When  local  bone  disease  is  present,  the 
indications  for  treatment  given  under  a  previous  liead- 

14 


2IO 


ANKYLOSIS    OF    THE    LOWER   JAW. 


ing  should  be  followed — that  is,  curetment  or  excision, 
etc.  Forcible  stretching  of  cicatricial  tissues  or  the 
division  of  bands  gives  no  permanent  results,  as  the 
irritation  is  increased  by  the  stretching,  and  the  divided 
bands  reunite.  The  formation  of  a  false  joint  in  front 
of  the  cicatricial  tissue  by  an  osteotomy  is  sometimes 
attempted,  but  all  these  measures  are  disappointing, 
although  improvement  sometimes  is  secured. 

The  treatment    is   tedious   and  painful,  and   usually 


Fig.  64. — Closure  of  twenty-seven  years'  duration,  due  to  osseous  anky- 
losis of  temporomaxillary  articulation,  showing  non-development  of  lower 
jaw  (Mears). 

discouraging  to  the  patient.  Mild  and  expectant  meth- 
ods should  be  thoroughly  exhausted  before  severer  steps 
are  undertaken. 

True  Ankylosis. — This  condition  means  either 
fibrous  or  bony  adhesions  within  the  temporomaxillary 
articulation.  The  causes  are  tubercular  or  rheumatic 
lesions  of  the  joint  proper,  rarely  traumatic  or  infective. 
Ankylosis  of  this  character  is  said  occasionally  to  follow 
middle-ear  disease,  scarlet  fever,  and  diphtheria. 

Symptoms. — The  fixation  of  the  joint  is  complete. 
After  the  acute  stage  there  is  no  pain  except  on  forcible 
movement.  Fulness  of  the  joint  can  often  be  felt  exter- 
nally.    The  history  will  complete  the  diagnosis. 


4 
SUMMARY.  211 


The  treatment  of  fibrous  ankylosis  when  there  is 
still  some  motion  under  forcible  manipulation  consists 
in  breaking  up  the  adhesions  under  an  anesthetic.  If 
this  can  be  safely  done,  a  wedge  of  cork  should  keep 
the  mouth  open  for  three  days.  After  this,  passive 
motion  should  be  carefully  kept  up  to  maintain  the 
movement  secured.  Unless  the  greatest  patience  is 
practised  disappointment  will  follow  from  recontrac- 
tion. 

When  the  ankylosis  is  due  to  bony  formations  resort 
must  be  had  to  osteotomy.  Various  methods  are  sug- 
gested. The  author  has  had  best  results  from  the  re- 
moval of  the  condyle  (Humphrey's  operation);  thus  by 
a  resection  removing  the  restriction  to  motion.  The 
only  risk  in  such  an  operation  is  hemorrhage  from  the 
internal  maxillary  artery,  which  passes  up  between  the 
internal  lateral  ligament  and  the  condyle.  The  artery 
is  avoided  by  attacking  the  condyle  from  the  outer  sur- 
face, and  enucleating  the  opened  joint  with  the  finger 
and  periosteal  elevator.  The  head  of  the  bone  when 
exposed  should  be  removed  with  wire  or  chain  saw,  and 
the  wound  closed  with  small  drain.  Passive  motion 
should  be  begun  after  a  week.     The  result  is  usually 

good. 

SUMMARY. 

Dislocations  are  separations  of  articulating  surfaces 
due  to  violence  and  muscular  contraction,  with  rupture 
of  the  ligaments  and  other  soft  parts,  sometimes  commu- 
nicating with  the  air.  When  complete  and  recent, 
diagnosis  is  easily  made  by  the  appearance  and  the  loss 
of  motion  and  power.  Reduction  should  be  made  at 
once,  usually  under  anesthesia,  as  muscular  opposition 
may  be  difficult  to  overcome.  All  dislocations  left 
unreduced  for  a  few  weeks  present  great  difficulties. 
Extension  and  manipulation  are  the  usual  steps.  When 
reduction  is  not  possible,  it  is  best  to  perform  an  arthrot- 
omy. 

The  lower  jaw  is  very  frequently  displaced  on  one  or 


212  ANKYLOSIS    OF   THE    LOWER   JAW. 

both  sides.  The  dislocation  is  usually  produced  by 
overextension.  The  diagnosis  is  simple  on  inspection. 
Reduction  is  easily  accomplished,  usually  even  with- 
out anesthesia.  Pressure  with  the  thumbs  on  the  molar 
teeth  will  throw  the  condyle  into  place.  After  reduc- 
tion a  bandage  should  be  worn  a  few  weeks  to  prevent 
recurrence.  Subluxation  is  due  to  muscular  relaxation 
and  requires  constitutional  treatment. 

Ankylosis  of  the  lower  jaw  may  be  due  to  a  painful 
wisdom-tooth  or  to  inflammation  of  the  soft  parts  in  the 
mouth ;  or  in  the  true  form  to  deposits  about  the  bony 
articulation.  When  due  to  muscular  spasm  or  pain  the 
treatment  is  expectant,  with  the  removal  of  accessible 
causes.  When  bands  have  formed  about  the  soft  parts, 
stretching  or  cutting  promises  very  little.  In  true 
ankylosis  involving  the  articulation,  if  the  adhesions 
cannot  be  broken  up  under  chloroform,  it  is  better  to 
excise  the  affected  condyle. 


CHAPTER    XXIX. 

FRACTURES,  WITH  SPECIAL  DESCRIPTIONS  OF  THE 
BONES  OF  THE  FACE. 

By  the  term  fracture  in  surgery  is  meant  the  breaking 
of  a  bone  into  two  or  more  pieces  as  the  result  of  a  vio- 
lence, either  mechanical  or  muscular. 

Varieties. — If  this  breaking  be  a  full  separation,  it  is 
termed  a  complete  fracture.  If  the  bone  be  bent  and  splin- 
tered, but  not  fully  separated,  it  is  termed  an  incomplete 
or  green-stick  fracture. 

All  complete  fractures  may  be  looked  on  as  of  two 
classes  or  varieties — simple^  or  closed,  fractures,  compound^ 
or  open,  fractures. 

Although  this  is  the  ordinary  division  of  fractures,  it 
is  perhaps  easiest  to  describe  all  variations  from  the 
simple  or  closed  fractures  as  complications.  Thus  simple 
fracture  is  a  break  of  the  bone  at  one  point,  hidden  by 
the  skin  and  overlying  tissues. 

When  the  bone  is  broken  in  more  than  one  place,  or 
when  several  bones  are  broken,  it  is  a  multiple  fracture. 
When  the  bone  is  shattered,  it  is  a  com^ninuted  fracture. 
When  similar  fractures  occur  in  corresponding  bones,  it 
is  called  a  double  fracture. 

When  any  one  of  these  injuries  communicates  with 
the  external  surface,  it  is  a  compound  or  open  fracture. 
When  at  the  time  of  accident  one  end  of  the  fractured 
bone  is  forced  into  the  other  it  is  an  impacted  fracture. 

When  dislocations  are  present,  or  when  arteries  are 
torn  or  the  soft  parts  are  extensively  lacerated,  the  frac- 
ture is  so  complicated.  These  various  complications  are 
merely  degrees  of  severity,  and  offer  additional  difficulty 
in  proportion  to  their  extent.     The  management  of  them 

213 


214     FRACTURES — SPECIAL  DESCRIPTIONS  OF  BONES  OF  FACE. 

is  rational  and  in  no  way  exceptional,  save  in  the  open 
or  compound  fracture,  which  is  subject  to  special  manage- 
ment, to  be  considered  presently. 

Forms  of  fracture  are  chiefly  transverse  and  oblique^ 
which  define  themselves.  When  the  bone  is  split  up  the 
shaft,  it  is  termed  longitudinal.  When  radiating,  as  in 
the  bone  of  the  skull,  the  fracture  is  termed  stellate. 
Other  fractures  have  special  names,  as  '^-shaped  and 
N -shaped  fractures. 

In  complete  fractures  the  displacement  is  lateral 
when  the  ends  slip  past  each  other ;  ajtgular  when 
the  direction  of  the  bone  is  so  altered  as  to  make  a 
distinct  angle  ;  rotary  when  the  axis  is  twisted  upon 
itself. 

The  causes  of  fracture  are  both  predisposing  and 
exciting.  Predisposing  causes  are  age.^  occupation^  and 
the  condition  of  general  health.  Certain  diseases,  as 
syphilis  and  rickets,  as  well  as  the  constitutional  condi- 
tion termed  fragilitas  osseu^n^  and  which  is  not  well 
understood,  lead  to  many  fractures  from  very  moderate 
violence.  Exciting  causes  are  violence  from  a  fall  or 
from  a  heavy  colliding  body,  or  a  fracture  may  result 
from  vigorous  muscular  contradion.  Mechanical  vio- 
lence may  act  directly  on  the  bone  at  the  point  of  break, 
or  indirectly  through  other  bones.  Thus  in  a  fall  the 
person  may  strike  a  resistance  with  the  leg  below  the 
knee  and  suffer  a  fracture  of  the  tibia  (direct  violence)  ; 
or  alighting  on  the  feet,  may  break  the  hip-joint  ;  or  on 
the  buttocks,  may  fracture  the  base  of  the  skull  (indirect 
violence). 

Symptoms  of  fracture  are  classically  three  :  preter- 
natural mobility^  or  a  false  joint  ;  crepitation  ;  and  actual 
loss  of  power.  These  three  symptoms  do  not  actually 
exist  together  in  any  other  form  of  injury.  Pain,  swell- 
ing, deformity,  and  shock  are  in  no  way  pathognomonic, 
but  succeed  dislocations  and  sprains  as  well. 

By  preternatural  mobility  is  meant  increased  freedom 
and  latitude  of  motion,  most  marked  under  an  anesthetic, 


PROCESS    OF    REPAIR    IN    FRACTURES.  21$ 

with  the  production  often  of  a  varying  deformity.  It  of 
itself  usually  clearly  indicates  fracture. 

Crepitation  is  the  sense  of  roughness  produced  by  rub- 
bing the  fractured  ends  together.  Often  a  sound  can  be 
heard,  but  chiefly  crepitus  is  determined  by  the  touch. 
It  discloses  the  presence  of  a  fracture. 

Loss  of  pozver  is  indicated  by  inability  to  lift  the  in- 
jured leg  or  hand.  Often  this  is  partly  due  to  the  pain 
caused  by  exertion,  but  care  will  show  there  is  actual 
loss  of  power  and  function. 

Diagnosis. — The  above  characteristic  symptoms  de- 
termine the  nature  of  the  injury.  An  opinion  in  doubtful 
cases  should  never  be  given  until  after  examination  under 
the  anesthetic. 

Deformity  in  dislocation  persists  only  until  reduced, 
and  then  does  not  recur  ;  in  fracture  it  is  easily  made  to 
disappear,  but  immediately  recurs  if  the  manipulation  is 
discontinued.  In  sprains  the  deformity  is  due  to  swell- 
ing, and  it  cannot  be  made  to  disappear.  The  compari- 
son with  the  corresponding  limb  as  to  measurements  and 
contour  is  of  great  value,  A  shortening  almost  invari- 
ably attends  fractures  of  the  long  bones.  Green-stick 
fractures  are  indicated  by  the  irreducible  deformity  in 
the  shaft  of  the  bone.  Such  form  is  usually  seen  in 
children  only.  In  elderly  people,  after  sixty  years  of 
age,  very  slight  violence  is  often  sufficient  to  cause  frac- 
ture of  the  neck  of  the  thigh-bone.  Separation  at  the 
epiphyseal  junction  is  seen  in  very  young  children,  with 
sometimes  great  deformity  and  displacement. 

Pain  and  extravasation  of  blood,  with  sometimes 
superficial  blisters  at  the  point  of  fracture,  are  valuable 
indicators. 

Process  of  Repair  in  Fractures. — The  steps  in  the 
repair  of  fractures,  like  those  in  the  repair  of  soft  parts,, 
consist  in  effiision  of  inflammatory  products.  These 
products,  called  lymph  in  the  soft  parts,  are  termed  callus 
in  the  bone.  This  callus  is  a  firm,  cartilaginous  material 
surrounding  the  separated  ends,  ensheathing  them  and 


2l6     FRACTURES SPECIAL  DESCRIPTIONS  OF  BONES  OF  FACE. 

fixing  them  in  position.  Gradually  this  material  be- 
comes organized  if  the  fragments  are  not  too  widely  sepa- 
rated, and  bony  union  takes  place.  The  excess  of  the 
callus  is  absorbed,  and  although  the  shaft  of  the  bone 
never  returns  exactly  to  its  normal  appearance,  and 
usually  is  found  to  contain  a  good  deal  of  redundant 
callus,  still  in  time  it  assumes  very  nearly  the  original 
size. 

Treatment  of  Fractures. — The  description  of  the 
complications  of  fractures,  as  well  as  their  treatment,  is 
perhaps  best  described  by  naming  them  individually. 
The  general  treatment  of  fractures  consists  first  in  trans- 
porting the  patient  to  some  place  of  safety,  and  then- 
setting  the  fractured  bone,  and  holding  it  in  place  by 
means  of  splints  and  bandages. 

In  the  ordinary  simple  fracture,  even  when  not  com- 
plicated with  the  form  of  double  or  multiple  fracture, 
usually  the  administration  of  an  anesthetic  is  required 
for  its  suitable  diagnosis  and  fixation.  After  the  an- 
esthetic is  administered  the  fractured  ends  are  placed  as 
nearly  as  possible  in  their  normal  relations,  and  steadied 
in  this  position  by  means  of  splints.  These  latter  may 
be  improvised  from  thin  boards  or  may  be  made  of 
material  already  prepared  from  tin  or  felt.  For  some 
forms  of  fractures  fixed  dressings  of  plaster-of-Paris  are 
employed.  Splints  are  held  in  place  by  bandages,  but 
they  should  always  be  well  padded,  and  the  limb  under- 
neath the  splints  should  be  protected  from  pressure  by 
cotton  batting.  It  is  not  advisable  to  apply  plaster-of- 
Paris  dressings  to  any  fracture  before  the  fifth  or  sixth 
day,  as  the  swelling  that  comes  on  directly  after  the 
injury  will  make  the  bandage  too  tight;  or  if  the  band- 
age is  put  on  after  the  swelling  has  occurred,  when  it 
subsides  the  dressing  will  have  become  too  loose. 

In  the  treatment  of  comminuted  fractures  it  may  be 
necessary  to  cut  down  upon  the  shattered  bone  and 
remove  the  fragments  if  accurate  apposition  of  them 
cannot  be  obtained.     It  is  to  be  remembered,  however, 


TREATMENT  OF  FRACTURES.  21/ 

that  excellent  results  are  often  obtained  where  considera- 
ble comminution  can  be  felt;  and,  besides,  the  conver- 
sion of  a  simple  fracture  into  a  compound  one  should 
never  be  lightly  undertaken.  Of  course,  it  is  under- 
stood that  all  antiseptic  and  aseptic  precautions  are  to  be 
taken  before  entering  upon  such  operative  steps. 

The  treatment  of  compound  fractures  is  a  much  more 
comprehensive  and  difficult  step  than  that  given  above. 
In  the  first  place,  a  compound  fracture  is  always  infected 
before  the  surgeon  sees  it.  If  it  involve  a  joint  or  is  in 
the  thigh,  the  immediate  danger  from  shock  is  often 
great.  The  prognosis  in  compound  fractures  involving 
very  large  bones  or  communicating  with  joints  is  essen- 
tially grave,  and  the  immediate  treatment  required  may 
be  amputation..  In  the  less  severe  form  of  compound 
fracture  the  first  step  after  the  patient  is  in  suitable  sur- 
roundings, preferably  in  an  infirmary,  is  thorough  cleans- 
ing of  the  wounded  surfaces;  control  of  all  hemorrhage; 
if  necessary,  enlarging  the  wound;  then  thoroughly 
scrubbing  all  the  wound  surfaces,  both  within  and  with- 
out, with  a  strong  solution  of  bichlorid  of  mercur}',  and 
providing  carefully  for  thorough  drainage.  In  a  few 
instances  it  may  be  permissible  to  close  up  a  compound 
fracture  with  sutures  and  dressings  without  drainage 
and  treat  it  as  a  simple  fracture.  The  ordinary  dressings 
placed  upon  a  fracture  should  be  removed  two  or  three 
times  within  the  first  ten  days  to  permit  inspection,  and, 
if  necessary,  reposition  of  the  fragments.  After  this 
time,  as  we  have  already  seen,  repair  has  progressed  so 
far  as  to  fix  the  fragments,  and  thus  prevent  displace- 
ment. Usually  the  fractured  bone  has  united  sufl5ciently 
to  permit  of  the  use  of  the  part  in  from  twenty  to  sixty 
days.  Fractures  repair  more  readily  in  the  young  and 
vigorous  than  in  the  old  and  infirm ;  also  smaller  bones 
unite  more  promptly  than  the  larger  ones. 

In  some  few  instances,  where  the  fracture  has  been 
improperly  fixed,  imperfect  union  results.  The  bony 
structures  are  replaced  by  fibrous  material,  and  a  false 


2l8  FRACTURES    OF    THE    LOWER   JAW. 

joint  is  formed.  In  some  cases  this  is  due  to  the  im- 
paired nutrition  of  the  patient,  but  most  commonly  to 
improper  fixation. 

FRACTURES  OF  THE  LOWER  JAW. 

Fracture  of  the  lower  jaw  is  one  of  the  most  common 
in  the  whole  body.  It  is  usually  due  to  direct  violence, 
as  a  fall  or  blow,  and  sometimes  is  the  result  of  crushing 
force.  The  bone  may  be  broken  in  either  of  the  rami, 
or  it  may  be  a  double  fracture,  simple,  comminuted,  or 
compound.  Sometimes  only  the  alveolar  border  is 
broken  off;  at  others,  the  coronoid  or  the  condyloid 
process.  In  fractures  of  the  alveolar  process  the  portion 
of  the  bone  may  be  still  adherent  in  its  normal  position, 
held  there  by  the  soft  parts;  or  it  may  be  completely 
separated.  Fractures  of  the  coronoid  process  occasion- 
ally occur  from  the  violent  contraction  of  the  temporal 
muscle.  Most  commonly  fractures  are  seen  in  the 
horizontal  body  of  the  bone.  Oftentimes  the  displace- 
ment in  this  form  of  fracture  is  slight.  The  line  of  the 
teeth  seems  to  be  a  little  irregular — the  displacement  is 
usually  upward  or  downward,  although  it  may  be 
inward  or  outward.  The  majority  of  fractures  of  the 
body  of  the  bone  are  compound,  as  the  structures  cover- 
ing the  bone  are  thin  and  the  violence  usually  ruptures 
them.  In  multiple  and  double  fractures,  especially  com- 
pound, the  displacement  is  greater,  and  often  great 
difficulty  is  experienced  in  holding  the  separated  frag- 
ments. 

Symptoms. — The  symptoms  of  fracture  of  the  in- 
ferior maxillary  bone  are  usually  well  marked.  The 
line  of  the  teeth  is  irregular,  the  displacement  can  be 
seen  as  well  as  felt,  and  in  the  majority  of  cases  there  is 
some  bloody  expectoration,  even  if  the  fracture  is  not 
actually  compound.  Pain  and  swelling  are  usually 
present;  crepitation  can  be  made  out  on  manipulation. 

The  prognosis  is  usually  favorable,  even  where  the 
fracture  is  compound.     In  neglected  cases,  however,  or 


TREATMENT. 


219 


where  extensive  injuries  are  present,  considerable  trouble 
is  experienced. 

Treatment. — The  treatment  of  unilateral  simple  frac- 
tures of  the  inferior  maxillary  bone  consists  first  in  the 
replacement  of  the  fragments,  and  then  in  their  sup- 
port and  fixation  by  suitable  splints.  The  mouth  should 
first  be  washed  out  with  listerin  and  water,  and  all 
bleeding  controlled.  The  most  suitable  simple  splint  is 
the  metal  splint  shown  in  figure  65.  In  its  absence  a 
substitute  can  be  made  of  sole  leather,  felt,  or  heavy 
paste-board.     The  splint  should  be  lined  with  a  layer  of 


,„rrr'ri 


Fig.  65. — Levis'  metallic  splint  for  fracture  of  the  lower  jaw. 


gauze,  and  held  in  place  preferably  by  the  Barton  band- 
age. The  apparatus  devised  by  Hamilton,  or  the  ordi- 
nary four-tailed  bandage,  answers  very  well.  In  double 
or  multiple  fractures,  however,  other  measures  are 
usually  required.  Fixation  may  often  be  accomplished 
by  fastening  together  the  teeth  on  each  side  of  the  break 
by  a  silver  wire  or  silk  ligature  wrapped  around  them; 
or,  if  there  are  not  teeth  adjacent  to  the  fracture,  a  band 
may  be  fastened  around  a  remote  tooth  to  which  a  short 
arm  is  attached.  Around  these  arms  the  wire  may  be 
wrapped  and  the  teeth  thus  steadied.  An  arm  may  be 
placed  upon  both  the  inner  or  outer  side  of  the  tooth, 


220 


FRACTURES    OF   THE    LOWER   JAW. 


and  thus  a  double  wire  may  be  applied.     In  compound 
fractures  where  there  is  much  displacement  the  wire  may 


Fig.  66. — "Four-tailed  bandage"  for  fracture  of  the  jaw. 

be  passed  through  the  body  of  the  bone  by  first  drilling 
a  hole  which  may  involve  a  part  or  the  entire  thickness 


Fig.  67. — Angle's  apparatus,  showing  adjustment. 

of  the  bone;  through  this  opening  silver  wires  may  be 
passed  and  fastened.  As  a  rule,  extensive  injuries  to  the 
maxillary  bone  are  compound,  at  least  upon  the  mucous 


TREATMENT. 


221 


surface,  but  where  these  operations  are  necessary  it  is 
advisable  to  make  an  incision  through  the  skin  as  well, 
if  access  cannot  be  secured  without  it. 

What  is  known  as  the  interdental  splint  is  perfected 
by  taking  an  impression,  and  then  upon  this  impression 
constructing  a  vulcanized  splint  to  which  arms  are 
attached.  Then  the  teeth  in  the  broken  portions  will 
fit  into  the  indentations  made  in  the  splint,  and  the 
arms  may  be  used  in  giving  support. 


Fig.  68. — Angle's  appliance  for  fracture  through  angle. 

Ansfle's  method  for  the  fixation  of  the  lower  broken 
jaw  to  the  intact  upper  one  is  effected  by  placing  bands 
upon  the  teeth  of  the  upper  and  lower  jaw,  and  around 
the  short  arms  fixed  upon  these  bands  wrapping  a  wire 
which  holds  them  together,  thus  using  the  upper  jaw 
as  a  splint.  These  bands  may  be  used  upon  both  sides 
of  the  jaw  if  the  fracture  is  complicated.  It  is  well 
to  remember  of  compound  fractures  of  the  lower  jaw 
that  they  respond  more  readily  to  treatment  than  open 
fractures  elsewhere.  As  a  rule,  it  is  not  possible  to  do 
any  closing  up  of  fractures  involving  the  mucous  mem- 
brane, especially   on   the  inner  side.      Compound  frac- 


222  FRACTURES    OF    THE    LOWER   JAW. 

tures  in  which  the  bones  are  wired  together  should  also 
be  left  open.  Where  fixation  is  effected  without  involv- 
ing the  mucous  membrane  the  external  wound  should 
be  closed  up  by  suture.  If  in  either  simple  or  com- 
pound fractures  suppuration  takes  place,  the  wound 
should  be  carefully  watched,  as  sometimes  the  pus  bur- 
rows down  beneath  the  jaw  and  points  either  in  the 
neck  or  in  the  pharynx.  Free  incision  and  drainage 
should  be  promptly  made  if  such  condition  arise,  and  if 
the  bone  be  found  diseased,  proper  steps  should  be  taken 
for  its  cure. 

Failure  of  union  resulting  in  ununited  fracture  is  not 
uncommon  in  the  inferior  maxilla.  The  cause  is 
doubtless  imperfect  fixation,  although  constitutional 
causes  often  are  combined.  The  treatment  consists  in 
freshening  the  ends  of  the  bone,  either  with  a  drill  or 
saw,  and  wiring  them  together.  If  such  wounds,  or 
similar  operative  wounds  for  the  primary  fracture,  can 
be  closed  up,  the  wire  may  be  left  indefinitely,  but  when 
kept  open,  the  wire  should  be  removed  in  two  or  three 
weeks,  as  soon  as  its  usefulness  is  past. 

Fracture  of  the  superior  maxillary  bone  is  a  condition 
of  great  severity,  due  usually  to  a  crushing  force,  and 
except  in  rare  instances  the  shock  and  injury  to  the  soft 
parts  are  of  more  importance  than  the  fracture.  Only 
in  fracture  of  the  alveolar  border  will  the  dentist  see 
such  cases  in  the  acute  stage.  Fracture  of  the  alveolar 
border  is  easily  diagnosticated  on  examination  :  crepitus 
and  movement  are  felt.  It  may  sometimes  be  necessary 
to  wire  the  fragments,  or  to  use  an  interdental  splint, 
but  usually  simple  replacement  will  be  all  that  is  re- 
quired. 

When  fracture  of  the  bones  of  the  face  has  occurred 
from  crushing  force  the  shock,  hemorrhage,  and  cere- 
bral complications  make  the  condition  one  for  the  gen- 
eral surgeon  ;  the  prognosis  is  grave.  After  a  few  days, 
if  the  patient  rallies  and  improves,  special  apparatus 
and  wiring  of  fragments  may  be  employed  as  indicated. 


TREATMENT    OF    NASAL    FRACTURE.  223 

Diet  after  the  less  severe  fractures  of  these  bones  is 
chiefly  liquid,  perhaps  administered  through  a  tube  in- 
troduced through  a  space  left  by  an  extracted  tooth. 
In  severe  injuries  rectal  feeding  may  be  required  for  a 
short  time. 

FRACTURE  OF  THE  NASAL  BONES. 

The  nasal  bones  are  quite  liable  to  fracture,  with  con- 
siderable displacement,  and  a  disfiguring  deformity  re- 
sults unless  proper  treatment  is  instituted. 

The  symptoms  are  the  deformity,  and  usually  crep- 
itus ;  hemorrhage  from  the  nose  and  occlusion  of  the 
nostrils  also  attend. 

The  treatment  consists,  after  stopping  the  hemor- 
rhage and  cleansing  the  nasal  tract  with  an  antiseptic 
irrigant,  in  restoring  the  normal  contour  of  the  nose  by 
pressure  and  manipulation.  Usually  this  can  be  easily 
done,  although  occasionally  both  reduction  and  main- 
tenance are  troublesome.  When  the  bridge  is  sunken, 
a  piece  of  rubber  tubing  carried  well  up  each  nostril 
will  hold  the  replaced  fragments,  at  the  same  time 
permitting  the  air  to  pass  through.  The  tube  can  be 
removed  on  the  fourth  day.  Where  this  plan  is  not 
efficient  or  is  not  tolerable  to  the  patient,  the  sides  of 
the  nose  may  be  transfixed  with  a  slender  needle  or  ]3in 
and  thus  held  together,  the  pin  being  removed  after 
three  or  four  days.  A  band  of  rubber  may  be  passed 
in  a  figure-of-eight  about  the  points  of  the  pin,  to  regu- 
late the  direction  of  the  pressure. 

When  the  bones  deviate  to  either  side,  the  septum 
may  be  transfixed  so  as  to  correct  the  deformity.  If  the 
pin  cannot  be  made  to  hold  the  bones  in  the  desired 
position,  rubber  bands  attached  to  the  end  of  the  pin 
and  secured  to  a  piece  of  adhesive  plaster  stuck  to  the 
cheek  may  be  employed  to  draw  the  bones  into  desired 
position. 

The  complete  correction  of  the  deformity'  should  be 
secured  before  concluding  the  first  dressings,  as  failure 


224  FRACTURE  OF  THE  NASAL  BONES. 

to   secure   normal   reposition   will   leave   a   reproachful 
monument  to  poor  skill. 

SUMMARY. 

Fractures  of  bone  are  complete  and  incomplete  (/.  e.^ 
bent  and  splintered).  They  are  open  and  closed,  with 
a  variety  of  complications.  They  are  caused  by  vio- 
lence and  muscular  action,  disease  and  age  predisposing. 
Fractures  are  due  to  indirect  violence  when  the  bone 
breaks  remote  from  the  injured  point.  False  joint,  crepi- 
tation, and  loss  of  power  are  characteristic. 

Union  takes  place  first  by  callus,  which  afterward 
becomes  partly  organized  and  partly  absorbed. 

Treatment  is  by  fixation  with  splints.  Compound  or 
open  fractures  require  antiseptic  cleansing  and  special 
care.  Non-union  is  sometimes  the  result  of  imperfect 
fixation. 

Fracture  of  the  lower  jaw,  single  or  double^  is  usually 
compound.  Simple  splint  is  often  all  that  is  required, 
but  in  double  fractures  wiring  may  be  needed.  There 
are  various  methods  of  wiring,  as  the  condition  sug- 
gests. 

Fracture  of  the  superior  maxilla  is  due  to  very  severe 
violence ;  usually  the  general  condition  is  grave. 

Fracture  of  the  nasal  bones  requires  care  in  adjust- 
ment of  the  fragments  to  avoid  mortifying  deformity. 


NDEX. 


Abscess,  alveolar,  149 
diagnosis  of,  1 50 
symptoms  of,  150 
treatment  of,  151 
diagnosis  of,  29 

differential,  29 
fluctuation  in,  29 
pitting  of,  29 
pointing  of,  29 
varieties  of,  28 
Acne  rosacea,  160' 
diagnosis  of,  161 
treatment  of,  161 
vulgaris,  161 
course  of,  162 
treatment  of,  162 
Acquired  syphilis,  115 
diagnosis  of,  120 
period  of  incubation  of,  116 
primary  stage  of,  116 
prognosis  of,  120 
secondary  stage  of,  116 
tertiary  stage  of,  119 
treatment  of,  120 
Acromegaly,  98,  196 
Actinomycosis,  54 
treatment  of,  56 
Adenoma,  95 
diagnosis  of,  96 
of  salivary  glands,  188 
prognosis  of,  96 
treatment  of,  96 
Air-passages,  foreign  bodies  in,  81 
Alveolar  abscess,  149 
diagnosis  of,  150 
symptoms  of,  150 
treatment  of,  151 
border,  cysts  of,  153 
symptoms  of,  154 
treatment  of,  154 
]5 


Anesthesia,  63 

general,  65 

spinal,  by  cocain,  65 
Angioma,  100 

diagnosis  of,  100 

of  gums,  147 

of  lips,  179 

treatment  of,  180 

of  tongue,  183 

treatment  of,  loi 
Angle's  apparatus  for  fracture  of 

jaw,  220 
Ankylosis,  false,  of  lower  jaw,  208 
treatment  of,  209 

of  lower  jaw,  208 

true,  of  lower  jaw,  210 
treatment  of,  211 
Antisepsis,  14 

in  operation,  60 
Antrum,  empyema  of,  193 
Apoplexy,  79 

embolic,  41 
Asepsis,  15 

in  operation,  60 
Aseptic  fever,  44 

treatment  of,  44 
Auto-infection,  43 

Bacteria,  destruction  of,  13 

forms  of,  1 5 
Bacteriolog}^  1 1 
Benign  tumors,  93 
Blush,  19 

Bone  disease   of  maxillary  sinus, 
196 
necrosis  of,  132,  134 
symptoms  of,  135 
treatment  of,  135 
tuberculosis  of,  125 
diagnosis  of,  127 

225 


226 


INDEX. 


Bone,  tuberculosis  of,  pathology  of, 
125 
treatment  of,  127 
Bones,  diseases  of,  131 

of  jaw,   necrosis  and  periosteal 
inflammations  of,  151 
Branchial  cyst,  113 
Burns,  82 

symptoms  of,  82 
treatment  of,  82 

Calculi,  salivary,  189 

treatment  of,  190 
Cancrum  oris,  159 

treatment  of,  160 
Carcinoma,  102 

diagnosis  of,  104 

encephaloid,  103 

epithelial,  103 

of  salivary  glands,  188 
treatment  of,  188 

of  tongue,  184 

scirrhous,  103 

treatment  of,  106 
Chancre  of  lips,  159,  181 

of  tongue,  184 
treatment  of,  184 
Cheiloplasty,  175 
Chemotaxis,  22 

Chlorofonn  as  an  anesthetic,  66 
Chondroma,  98 

of  gums,  146 
Cleft-palate,  171 
Cloaca,  132,  135 
Cocain,  spinal  anesthesia  by,  65 
Columnar  epithelioma,  106 
Congestion,  19 
Contused  wounds,  73 
treatment  of,  73 
Cysts,  112 

branchial,  113 

congenital,  112 

extravasation,  112 

exudation,  112 

mucous,  112 

neoplasm,  112 

of  alveolar  border,  153 
symptoms  of,  154 
treatment  of,  154 


Cysts  of  maxillary  sinus,  195 
parasitic,  114 
retention,  112 

Deflection  of  nasal  septum,  169 
Deformity  of  nose,  166 
Dermoids,  113 
Diapedesis,  21 
Dislocations,  204 

of  lower  jaw,  205 
treatment  of,  207 

treatment  of,  205 
Dry  gangrene,  38 
symptoms  of,  38 

Ear,  foreign  bodies  in,  81 
Elephantiasis,  136 
Embolic  apoplexy,  41 
Embolism,  41 
Embolus,  42 
Emergencies,  78 

Empyema,     chronic,     of    frontal 
sinus,  170 
treatment  of,  170 
of  antrum,  193 
Encephaloid  carcinoma,  103 
Epilepsy,  79 
Epistaxis,  89 

treatment  of,  89 
Epithelial  carcinoma,  103 
Epithelioma,  columnar,  106 
of  face,  157 
of  lips,  180 

diagnosis  of,  181 
treatment  of,  181 
of  tongue,  141,  184 
diagnosis  of,  141,  185 
treatment  of,  141,  185 
Epulis,  143 
Erysipelas,  52 
facial,  53 

symptoms  of,  53 
treatment  of,  53 
forms  of,  52 
general,  52 
phlegmonous,  52 
symptoms  of,  52 
treatment  of,  52 
Ether  as  an  anesthetic,  65 


INDEX. 


227 


Extravasation  cysts,  112 
Exudation  cysts,  112 
Eye,  foreign  bodies  in,  80 

Face,  epithelioma  of,  1 57 
diagnosis  of,  1 58 
erysipelas  of,  53 

treatment  of,  53 
lupus  exedens  of,  156 
vulgaris  of,  1 56 
treatment  of,  1 56 
surgical  lesions  of,  1 56 
Fibrin,  21 
Fibroma,  96 

of  gums,  143 
Fibromatous  polypi  in  nose,  166 
Fistula,  33 
salivary,  190 

treatment  of,  191 
treatment  of,  34  • 
Foreign  bodies  in  air-passages,  81 
in  ear,  81 
in  eye,  80 
in  larynx,  81 
in  nose,  81 
in  pharynx,  81 
in  trachea,  81 
Four-tailed    bandage    for  fracture 

of  jaw,  220 
Fractures,  213 

compound,  treatment  of,  217 
of  lower  jaw,  218 

treatment  of,  219 
of  nasal  bones,  223 
treatment,  223 
process  of  repair  in,  215 
simple,  treatment  of,  216 
treatment  of,  216 
varieties  of,  213 
Frontal   sinus,    chronic   empyema 
of,  170 
treatment  of,  170 

Gangrene,  38 
causes  of,  38 
dry,  38 

symptoms  of,  38 
moist,  39 

symptoms  of,  39 


Gangrene,  moist,  treatment  of,  39 
Giant-celled  sarcoma,  109 
Gingivitis,  139 
symptoms  of,  139 
treatment  of,  139 
Gums  and  alveolar  border,  tumors 
of,  143 
and  mouth,  scurvy  of,  141 
symptoms  of,  141 
treatment  of,  142 
tubercular  ulcerations  of,   140 
ulcers  of,  139 
diagnosis  of,  140 
treatment  of,  140 
angioma  of,  147 
chondromata  of,  146 
fibroma  of,  143 
osteoma  of,  146 
sarcoma  of,  148 
diagnosis  of,  149 
treatment  of,  149 
Gunshot  wounds,  T"] 

Harelip,  174 

varieties  of,  174 
Healthy  ulcers,  31 
Hemophilia,  88 

symptoms  of,  88 

treatment  of,  89 
Hemorrhage,  85 

diagnosis  of,  87 

nasal,  89 

treatment  of,  89 

primary,  85 

reactionary,  85 

secondary,  86 

symptoms  of,  86 

treatment  of,  87 
Hemorrhagic  ulcers,  31 
Heterologous  tumors,  93 
Hodgkin's  disease,  137 
Homologous  tumors,  93 
Hydrophobia,  78 

treatment  of,  78 
Hyperemia,  19 

active,  19 

passive,  19 
Hyperplasia,  20 
Hypertrophy  of  tongue,  183 


228 


INDEX. 


Immunity  from  syphilis,  ii8 
Incised  wounds,  74 

treatment  of,  74 
Indolent  ulcers,  31 
Infected  wounds,  75 
treatment  of,  75 
Inflammation,  19 

phlegmonous,  treatment  of,  26 
resolution  of,  23 
treatment  of,  25 
wet  cups  in,  25 
Inherited  syphihs,  122 
symptoms  of,  122 
treatment  of  123 
Involucrum,  133,  135 
Irritable  ulcers,  31 

Jaw,  bones  of,  diseases  of,  151 

necrosis     and    periosteal    in- 
flammations of,  151 
lower,  ankylosis  of,  208 
dislocations  of,  205 
treatment  of,  207 
false  ankylosis  of  208 
treatment  of,  209 
fractures  of,  218 

treatment  of,  219 
subluxation  of  208 
true  ankylosis  of,  210 
treatment  of,  211 
necrosis  of,  151 

treatment  of  1 52 
phosphorus  necrosis  of,  152 
course  of,  153 
diagnosis  of,  153 
symptoms  of  152 
treatment  of,  153 

Karyokinesis,  35 
Keloids,  164 

Lacerated  wounds,  treatment  of, 

73 
Lane's   operation  for   cleft-palate, 

173 
Leeches  in  inflammation,  25 
Leontiasis,  98,  197 
Levis's  metallic  splint  for  fracture 

of  lower  jaw,  219 


Lipoma,  97 
Lips,  angioma  of,  179 
treatment  of,  180 
chancre  of,  159,  181 
epithelioma  of,  180 
diagnosis  of,  181 
treatment  of,  181 
lesions  of,  179 
Lupus,  128 

exedens  of  face,  156 
treatment  of,  129 
vulgaris  of  face,  156 
treatment  of,  1 57 
Lymphadenoma,  137 
Lymphangitis,  136 
Lymphatic  glands  of  neck,  tuber- 
culosis of,  129 
tuberculosis  of,  diagnosis  of, 
129 
treatment  of,  129 
Lymphatics,  diseases  of,  136 

obstruction  of  136 
Lymphedema,  136 
Lymphoma,  malignant,  137 
Lymphosarcoma,  109 

Macroglossia,  183 
Mahgnant  lymphoma,  137 

tumors,  93 
Maxillary  sinus,  bone  disease   of, 
196 
cysts  of,  195 
diseases  of  193 
polypi  of,  195 
Metastases,  102 
Moist  gangrene,  39 
symptoms  of,  39 
treatment  of  39 
Mouth   and   face,  surgical  lesions 
of  156 
and  gums,  scurvy  of  141 
symptoms  of  141 
treatment  of  142 
tubercular  ulcerations  of  140 
ulcers  of,  139 
diagnosis  of  140 
treatment  of  140 
Mucous  cysts,  112 
Myeloid  sarcoma,  109 


INDEX. 


229 


Nasal  bones,  fracture  of,  223 
treatment  of,  223 
hemorrhage,  89 

treatment  of,  89 
septum,  deflection  of,  169 
Neck,  lymphatic  glands  of,  tuber- 
culosis of,  129 
treatment  of,  129 
Necrosis  and  periosteal  inflamma- 
tions of  bones  of  jaw, 

151 
of  bone,  132,  134 
symptoms  of,  135 
treatment  of,  135 
of  jaw,  151 

treatment  of,  152 
phosphorus,  of  jaw,  152 
treatment  of,  153 
Neoplasm  cysts,  112 
Neuralgia,  199 

treatment  of,  200 
Nevus,  100 

treatment  of,  loi 
Nitrous  oxid  as  an  anesthetic,  68 
Noma,  159 

treatment  of,  160 
Nose,  deformity  of,  166 
foreign  bodies  in,  81 
polypi  in,  166 

treatment  of,  166 
surgery  of,  166 

Odontoma,  99 

diagnosis  of,  100 

origin  of,  99 

treatment  of,  100 
Operation,  antisepsis  in,  60 

asepsis  in,  60 

preparations  for,  59 

sepsis  in,  60 
Osteoma,  98 

of  gums,  146 
Osteomyelitis,  132 

diagnosis  of,  134 

treatment  of,  134 

tubercular,  127 
Osteoperiostitis,  131 

diagnosis  of,  132 

treatment  of,  132 


Papilloma,  94 
Papilloma,  diagnosis  of,  95 

treatment  of,  95 
Parasitic  cysts,  114 
Parotid    gland,    chronic    suppura- 
tions of,  187 
tumor,  189 
Periosteal  inflammations  and  ne- 
crosis of bones  of  jaw,  151 
Periostitis,  131 
diagnosis  of,  132 
treatment  of,  132 
tubercular,  127 
Phagedenic  ulcers,  31 
Phagocytosis,  22 
Pharynx,  foreign  bodies  in,  81 
Phlegmonous  erysipelas,  52 
symptoms  of,  52 
treatment  of,  52 
inflammation,  treatment  of,  26 
Phosphorus  necrosis  of  jaw,  152 
diagnosis  of,  153 
treatment  of,  153 
Poisoned  wounds,  76 
symptoms  of,  76 
treatment  of,  76 
Polypi  in  nose,  166 
treatment  of,  166 
of  maxillary  sinus,  195 
Process  of  repair,  34 
in  fractures,  215 
Ptomains,  12 
Punctured  wounds,  75 

treatment  of,  75 
Pus,  27 

hemorrhagic,  28 
ichorous,  28 
Pyemia,  50 

symptoms  of,  50 
treatment  of,  51 

Ranula,  191 

treatment  of,  191 
Repair,  first  intention,  35 

process  of,  34 
in  fractures,  215 

second  intention,  35 
Retention  cysts,  112 
Rhinophyma,  i6o 


230 


INDEX. 


Rodent  ulcer,  104,  158 
Round-celled  sarcoma,  108 

Salivary  calculi,  189 

treatment  of,  190 
fistula,  190 

treatment  of,  191 
glands,  adenoma  of,  188 

carcinoma  of,  188 
treatment  of,  188 

diseases  of,  187 

infections  of,  187 

suppurations  of,  187 
Sapremia,  45 
prognosis  of,  46 
treatment  of,  46 
Sarcoma,  108 
course  of,  no 
diagnosis  of,  in 
giant-celled,  109 
of  gums,  148 

diagnosis  of,  149 

treatment  of,  149 
prognosis. of,  1 11 
round-celled,  108 
spindle-celled,  109 
symptoms  of,  no 
treatment  of,  in 
Schleich's  mixture  as  an  anesthetic, 

Scirrhous  carcinoma,  103 
Scurvy  of  gums  and  mouth,  141 

treatment  of,  142 
Sebaceous  tumors  of  face,  164 
Sepsis  in  operation,  60 

of  wounds,  73 
Septicemia,  46 

treatment  of,  48 
Sequestrum,  133,  135 
Serpiginous  ulcers,  31 
Shock,  71 

prognosis  of,  72 

treatment  of,  72 
Sinus,  33 

treatment  of,  34 
Skin,  tuberculosis  of,  128,  156 

treatment  of,  129,  157 
Spinal  anesthesia  by  cocain,  65 
Spindle-celled  sarcoma,  109 


Stagnation,  19 

Staphylococcus   pyogenes   aureus, 

16 
Staphylorrhaphy,  171 
Streptococcus  pyogenes,  16 
Subluxation  of  lower  jaw,  208 
Suffusion,  19 
Sunstroke,  80 

treatment  of,  80 
Suppuration,  27 
definition  of,  27 
treatment  of,  29 
Surgical  diagnosis,  57 
fever,  44 

definition  of,  48 
treatment  of,  44 
Syphihs,  115 
acquired,  115 
diagnosis  of,  120 
period  of  incubation  of,  116 
primary  stage  of,  116 
prognosis  of,  120 
secondary  stage  of,  116 
tertiary  stage  of,  119 
treatment  of,  120 
immunity  from,  118 
inherited,  122 

treatment  of,  123 
of  tongue,  183 

Thrombosis,  41 
Tic  douloureux,  199 

treatment  of,  201 
Tongue,  carcinoma  of,  184 
chancre  of,  184 

treatment  of,  184 
epithelioma  of,  141,  184 
diagnosis  of,  141,  185 
treatment  of,  141,  185 
hypertrophy  of,  183 
lesions  of,  183 
syphilis  of,  183 
tuberculosis  of,  184 
treatment  of,  184 
Trachea,  foreign  bodies  in,  81 
Tubercular  osteomyelitis,  127 
periostitis,  127 

ulcerations  of  mouth  and  gums, 
140 


INDEX. 


231 


Tuberculosis  of  bone,  125 
diagnosis  of,  127 
pathology  of,  125 
treatment  of,  127 
of  lymphatic   glands    of    neck, 
129 
treatment  of,  129 
of  skin,  128,  156 

treatment  of,  129,  157 
of  tongue,  184 
treatment  of,  184 
Tumor,  parotid,  189 
Tumors,  92 
benign,  93 
cause  of,  92 
classification  of,  93 
diagnosis  of,  93 
heterologous,  93 
homologous,  93 
malignant,  93 
of   gums   and   alveolar  border, 

143 
pathology  of,  92 
sebaceous,  efface,  164 
Typhoid  state,  26 

Ulcer,  rodent,  104,  158 

treatment  of,  32 
Ulceration,  31 


Ulcers,  31 

causes  of,  31 

definition  of,  37 

healthy,  31 

of  gums  and  mouth,  139 
diagnosis  of,  140 
treatment  of,  140 

unhealthy,  31 

varieties  of,  31 
Unhealthy  ulcers,  31 
Uranoplasty,  172 

Wet  cups  in  inflammation,  25 
Wounds,  73 
contused,  73 

treatment  of,  73 
gunshot,  77 
incised,  74 

treatment  of,  74 
including  shock,  70 
infected,  75 

treatment  of,  75 
lacerated,  treatment  of,  73 
poisoned,  76 

treatment  of,  76 
punctured,  75 

treatment  of,  75 
sepsis  of,  73 


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Test  for  Color-Bhndness  Hysteric  Alopecia  of  the  Eyelids  ;  Metastatic  Gonor- 
rheal Conjunctivitis  ;  Grill-like  Keratitis  (Haab);  the  so-called  Holes  in  the  Macula  ; 
Divergence-paralysis  ;  Convergence-paralysis,  and  many  others.  A  large  number 
of  therapeutic  agents  comparatively  recently  introduced,  particularly  the  newer 
silver  salts,  are  given  in  connection  with  the  diseases  in  which  they  are  indicated. 
The  illustrative  feature  of  the  work  has  been  greatly  enhanced  in  value  by  the 
addition  of  many  new  cuts  and  six  full-page  chromo-lithographic  plates,  all  most 
accurately  portraying  the  pathologic  conditions  which  they  represent. 


PERSONAL  AND   PRESS  OPINIONS 


Samuel  Theobald,  M.D., 

Clinical  Professor  of  Ophthalmology,  Johtis  Hopkins  University,  Baltimore. 
"  It  is  a  work  that  I  have  held  in  high  esteem,  and  is  one  of  the  two  or  three  books  upon 
the  eye  which  I  have  been  in  the  habit  of  recommending  to  my  students  in  the  Johns  Hopkins 
Medical  School." 

Late  William  Pepper.  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine,  University  of  Penn- 
sylvania. 
"X  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  also  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

British  Medical  Journal  t 

"  A  clearly  written,  comprehensive  manual.  One  which  we  can  commend  to  students  as  a 
reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon  the 
study  of  this  special  branch  of  medical  science." 


SAUNDERS'   BOOKS    ON 


Barton  and  Well^* 
Medical  Thesaurus 

A   NEW   WORK— JUST   ISSUED 


A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  A.  M.,  Assistant  to  Professor  of  Materia  Medica  and  Thera- 
peutics, and  Lecturer  on  Pharmacy,  Georgetown  University,  Washing- 
ton, D.  C. ;  and  Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryn- 
gology, Georgetown  University,  Washington,  D.  C.  Handsome  i2mo 
of  534  pages.  Flexible  leather,  ^2.50  net;  with  thumb  index,  ^3.00 
net. 

THE  ONLY   MEDICAL  THESAURUS   EVER   PUBLISHED 

This  work  is  unique  in  that  it  is  the  only  Medical  Thesaurus  ever  published. 
Instead  of  supplying  the  meaning  to  given  words,  as  an  ordinary  dictionary  does, 
it  reverses  the  process,  and  when  the  meaning  or  idea  is  in  the  mind  it  endeavors 
to  supply  the  fitting  term  or  plirase  to  express  that  idea.  This  Thesaurus  will  be 
of  service  to  all  persons  who  are  called  upon  to  state  or  explain  any  subject  in  the 
technical  language  of  medicine. 

Boston  Medical  and  Surgical  Journal 

"  We  can  easily  see  the  value  of  such  a  book,  and  can  certainly  recommend  it  to  our 
readers." 

Saxe*s  Urinalysis 


Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
Pathologist  to  Columbus  Hospital,  New  York  City.  i2mo  of  about 
300  pages,  fully  illustrated.     Flexible  leather. 

JUST   ISSUED 

This  work  is  intended  both  for  the  student  in  the  laboratory  and  for  the  busy 
practitioner  in  his  office.  In  his  practical  experience  the  author  has  devised  many 
new  methods  of  technic,  which  he  has  carefully  described  and  illustrated. 


EYE,   EAR,   NOSE,   AND    THROAT. 


American  Text-Book  qf 
Eye,  Ear,  Nose,  and  Throat 


American  Text=Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweinitz,  M.D.,  Professor  of  Ophthal- 
mology in  the  University  of  Pennsylvania  ;  and  B.  Alexander  Randall, 
M.  D.,  Clinical  Professor  of  Diseases  of  the  Ear  in  the  University  of 
Pennsylvania.  Imperial  octavo,  125  i  pages,  with  766  illustrations,  59 
of  them  in  colors.    Cloth,  ^7.00  net;  Sheep  or  Half  Morocco,  ;^8.00  net. 

This  work  is  essentially  a  text-book  on  the  one  hand,  and,  on  the  other,  a 
volume  of  reference  to  which  the  practitioner  may  turn  and  find  a  series  of  articles 
written  by  representative  authorities  on  the  subjects  portrayed  by  them.  There- 
fore, the  practical  side  of  the  question  has  been  brought  into  prominence.  Par- 
ticular emphasis  has  been  laid  on  the  most  approved  methods  of  treatment. 

Americ&n  Journal  of  the  Medic&l  Sciences 

"  The  different  articles  are  complete,  forceful,  and,  if  one  may  be  permitted  to  use  the  term, 
'snappy,'  in  decided  contrast  to  some  of  the  labored  but  not  more  learned  descriptions  which 
have  appeared  in  the  larger  systems  of  ophthalmology." 


Hyde  and  Montgomery's 
Syphilis   and  Venereal 


Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.  D.,  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Associate  Professor  of  Skin,  Genito- 
Urinary,  and  Venereal  Diseases  in  Rush  Medical  College,  in  Affiliation 
with  the  University  of  Chicago,  Chicago.  Octavo  volume  of  594  pages, 
profusely  illustrated.      Cloth,  ^4.00  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED 

In  this  edition  every  page  has  received  careful  revision  ;  many  subjects, 
notably  that  on  Gonorrhea,  have  been  practically  rewritten,  and  much  new  mate- 
rial has  been  added.  A  number  of  new  cuts  have  also  been  introduced,  besides 
a  series  of  beautiful  colored  lithographic  plates. 

American  Journal  of  Cutaneous  and  Genito-Urinary  Diseases 

"  It  is  a  plain,  practical,  and  up-to-date  manual  containing  just  the  kind  of  information 
that  physicians  need  to  cope  successfully  with  a  troublesome  class  of  diseases." 


SAUNDERS'    BOOKS   ON 


THE  BEST  /Vm  eric  Sin  standard 

Illustrated  Dictionary 

Third  Revised  Edition— Just  Issued 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches  ;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  800  pages,  bound  in  full  flexible  leather. 
Price,  ^4.50  net;  with  thumb  index,  55-00  i^et. 

THREE  EDITIONS  IN  THREE  YEARS -WITH  15OO  NEW  TERMS 

In  this  edition  the  book  has  been  subjected  to  a  thorough  revision.  The 
author  has  also  added  upward  of  fifteen  hundred  important  new  terms  that  have 
appeared  in  medical  literature  dunng  the  past  few  months. 

Howard  A.  Kelly,  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkms  University,  Baltimore. 

"  Dr.  Dorland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

American  Year-Book 


Saunders'   American  Year=Book  of  Medicine  and  Surgery.     A 

Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
Branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged,  with  critical  editorial  comments,  by  eminent 
American  specialists,  under  the  editorial  charge  of  George  M.  Gould, 
A.  M.,  M.  D.  In  two  volumes  :  Vol,  I. —  General  Medicine,  octavo,  715 
pages,  illustrated ;  Vol.  II. — General  Stirgery,  octavo,  684  pages,  illus- 
trated. Per  vol. :  Cloth,  ;^3.oo  net ;  Half  Morocco,  ;^3.75  net.  Sold 
by  Subscription. 

In  these  volumes  the  reader  obtains  not  only  a  yearly  digest,  but  also  the 
invaluable  annotations  and  criticisms  of  the  editors.  As  usual,  this  issue  of  the 
Year-Book  is  amply  illustrated. 

The  Lancet.  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .   .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


NOSE,    THROAT,  AND   EAR. 


Cradle's 
Nose,  Pharynx,  and  Ear 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Gradle, 
M.  D.,  Professor  of  Ophthalmology  and  Otology,  Northwestern  Uni- 
versity Medical  School,  Chicago.  Handsome  octavo  of  547  pages, 
illustrated,  including  two  full-page  plates  in  colors.     Cloth,  ^3.50  net. 

INCLUDING  TOPOGRAPHIC  ANATOMY 

This  volume  presents  diseases  of  the  Nose,  Phar}mx,  and  Ear  as  the  author 
has  seen  them  during  an  experience  of  nearly  twenty-five  years.  In  it  are 
answered  in  detail  those  questions  regarding  the  course  and  outcome  of  diseases 
which  cause  the  less  experienced  observer  the  most  anxiety  in  an  individual  case. 
Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  Medical  Jotimal 

"This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  confusion 
incident  to  a  categorical  statement  of  everybody's  opinion." 

Kyle's 
Diseases  of  Nose  am)  Throat 


Diseases  of  the  Nose  and  Throat.     By  D.  Braden  Kyle,  M.  D., 

Professor  of  Laryngology  and  Rhinology  in  the  Jefferson  Medical 
College,  Philadelphia ;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Octavo,  669  pages;  over  175  illus- 
trations, and  6  lithographic  plates  in  colors.     Cloth,  $4.00  net. 

JUST    ISSUED— THIRD    REVISED    EDITION 

Three  large  editions  of  this  excellent  -.vork  fully  testify  to  its  practical 
value.  In  this  edition  the  author  has  revised  the  text  thoroughly,  bringing 
it  absolutely  down  to  date.  With  the  practical  purpose  of  the  book  in  mind,  ex- 
tended consideration  has  been  given  to  treatment,  each  disease  being  considered  in 
full,  and  definite  courses  being  laid  down  to  meet  special  conditions  and  symptoms. 

Dudley  S.  Reynolds.  M.  D.. 

Formerly  Professor  of  Ophthalmology  and  Otology,  Hospital  College  of  Medicine,  Louisville. 

"  It  is  an  important  addition  to  the  text-books  now  in  use,  and  is  better  adapted  to  the  uses 
of  the  student  than  any  other  work  with  which  I  am  famihar.  I  shall  be  pleased  to  commend 
Dr.  Kyle's  work  as  the  best  text-book." 


SAUNDERS'    BOOKS    ON 


Brtihl,  Politzer,  and  Smith's 
Otology 


Atlas  and  Epitome  of  Otology.  By  Gustav  Bruhl,  M.  D.,  of 
Berlin,  with  the  collaboration  of  Professor  Dr.  A.  Politzer,  of 
Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith,  M.  D.,  Clin- 
ical Professor  of  Otology,  Jefferson  Medical  College,  Philadelphia. 
With  244  colored  figures  on  39  lithographic  plates,  99  text  illustra- 
tions, and  292  pages  of  text.  Cloth,  ;^3.oo  net.  In  Saunders'  Hand- 
Atlas  Series. 

INCLUDING  ANATOMY  AND  PHYSIOLOGY 

The  work  is  both  didactic  and  clinical  in  its  teaching.  A  special  feature  is 
the  very  complete  exposition  of  the  minute  anatomy  of  the  ear,  a  working  knowl- 
edge of  which  is  so  essential  to  an  intelligent  conception  of  the  science  of  otology. 
The  association  of  Professor  Politzer  and  the  use  of  so  many  \aluable  specimens 
from  his  notably  rich  collection  especially  enhance  the  value  of  the  treatise.  The 
work  contains  everything  of  importance  in  the  elementary  study  of  otology. 

Clarence  J.  Blake.  M.  D., 

Professor  of  Otology  in  Harvard  University  Medical  School,  Boston. 

"  The  most  complete  work  of  its  kind  as  yet  publislied,  and  one  commending  itself  to  both 
the  student  and  the  teacher  in  the  character  and  scope  of  its  illustrations." 


Grtinwald  anb  Grayson's 
Diseases  of  the  Larynx 

Atlas   and    Epitome  of    Diseases  of   the    Larynx.       By    Dr.   L 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P.  Gray- 
son, M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hos- 
pital of  the  University  of  Pennsylvania.  With  107  colored  figures  on 
44  plates,  25  text-illustrations,  and  103  pages  of  text.  Cloth,  ^2.50 
net.     In  Saunders'  Hand-Atlas  Sei^ies. 

In  this  work  the  author  has  given  special  attention  to  the  cUnical  portion,  the 
sections  on  diagnosis  and  treatment  being  particularly  full.  The  plates  portray, 
with  a  remarkable  fidelity  to  nature,  pathologic  conditions  that  it  would  require 
a  number  of  years  to  duplicate  in  practice.  A  knowledge  of  the  histology  of  the 
morbid  processes  being  essential  to  a  proper  understanding  of  them,  twelve  plates, 
showing  the  most  important  elementary  alterations,  have  been  included. 

British  Medical  Journal 

"  Excels  everything  we  have  hitherto  seen  in  the  way  of  colored  illustrations  of  diseases  of 
the  larynx.  .  .  .  Not  only  valuable  for  the  teaching  of  laryngology,  it  will  prove  of  the  greatest 
help  to  those  who  are  perfecting  themselves  by  private  study." 


DISEASES    OF    THE   EYE. 


Haab  and  DeSchweinitz's 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
98  colored  illustrations  on  48  lithographic  plates  and  232  pages  ot 
text.     Cloth,  33.00  net.     /;/  Saunders'  Hand-Atlas  Series. 

SECOND    REVISED    EDITION  — JUST   ISSUED 

Conditions  attending  diseases  of  the  external  eye,  which  are  often  so  compUcated, 
have  probably  never  been  more  clearly  and  comprehensively  expounded  than  in 
the  forelying  work,  in  which  the  pictorial  most  happily  supplements  the  verbal 
description.     The  price  of  the  book  is  remarkably  low. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited   to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 

Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Ziirich.  From  the  Third  Rezused 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M.  D.,  Professor  of  Ophthahnology,  University  of 
Pennsylvania.  With  152  colored  lithographic  illustrations  and  85 
pages  of  text.     Cloth,  $3.00  net.     In  Saunders  Hand-Atlas  Series. 

The  great  value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  English 
translation.  Not  only  is  the  student  made  acquainted  with  carefullv  prepared 
ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the  most  im- 
portant fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic  lesions 
are  added.     The  whole  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet,  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
every  hospital  into  which  ophthalmic  cases  are  received." 


lo  SAUNDERS'    BOOKS   ON 

American   Text-Book   of 

Genito-Urinary,  Syphilis,  Skin 

American  Text=book  of  Genito=Urinary  Diseases,  Syphilis,  and 
Diseases  of  the  Sl<in.      Edited  by  L.  Bolton  Bangs,  M.  D.,  late  Prof. 

of  Genito-Urinary  Surgery,  University  and  Bellevue  Hospital  Medical 
College,  New  York  ;  and  W.  A.  Hardaway,  M.  D.,  Professor  of  Diseases 
of  the  Skin,  Missouri  Medical  College.  Imperial  octavo,  1229  pages, 
with  300  engravings,  20  colored  plates.  Cloth,  ^7.00  net;  Sheep  or 
Half  Morocco,  ^8.00  net. 

CONTAINING  20  COLORED  PLATES 

This  work  is  intended  for  both  the  student  and  practitioner,  giving,  as  it  does, 
a  comprehensive  and  detailed  presentation  of  the  subjects  discussed.  The  work 
is  original  and  fully  representative.  The  illustrations,  many  of  which  are  in 
colors,  portray  the  conditions  with  rare  fidelity,  and  will  be  found  invaluable  as 
an  aid  in  diagnosis. 

Journal  of  the  American  MediceJ  Association 

"  This  voluminous  work  is  thoroughly  up-to-date,  and  the  chapters  on  genito-urinary  dis- 
eases are  especially  valuable.  The  illustrations  are  fine  and  are  mostly  original.  The  section 
on  dermatology  is  concise  and  in  every  way  admirable." 

SennV 

Genito-Urinary  Tuberculosis 

Tuberculosis  of  the  Qenito=Urinary  Organs,  Male  and  Female. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor  of  Surgery  in  Rush  Med- 
ical College ;  Attending  Surgeon  to  the  Presbyterian  Hospital,  Chicago. 
Octavo  volume  of  317  pages,  illustrated.     Cloth,  ^§3.00  net. 

MALE  AND  FEMALE 

Tuberculosis  of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal  affection  that  a  special  treatise  on  the  subject  appears  to  fill  a 
gap  in  medical  literature.  In  the  present  work  the  bacteriology  of  the  subject  has 
received  due  attention,  the  modern  resources  employed  in  the  differential  diagnosis 
between  tubercular  and  other  inflammatory  affections  are  fully  described,  and  the 
medical  and  surgical  therapeutics  are  discussed  in  detail. 

British  Medical  Journal 

"  The  book  will  well  repay  perusal.  It  is  the  final  word,  as  our  knowledge  stands,  upon 
the  diseases  of  which  it  treats,  and  will  add  to  the  reputation  of  its  distinguished  author." 


DISEASES   OF   THE  SKIN. 


Mracek  anb  Stelwagon*s 
Diseases  of  the  Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof.  Dr.  Franz 
Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  College, 
Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and 
200  pages  of  text.     Cloth,  $3.50  net.     In  Saunders'  Hand- Atlas  Series. 

CONTAINING   63   COLORED    PLATES 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  contains, 
together  with  colored  plates  of  unusual  beauty,  numerous  illustrations  in  black, 
and  a  text  comprehending  the  entire  field  of  dermatology.  The  illustrations  are 
all  original  and  prepared  from  actual  cases  in  Mracek' s  clinic,  and  the  execution 
of  the  plates  is  superior  to  that  of  any,  even  the  most  expensive,  dermatologic 
atlas  hitherto  published. 

American  Journal  of  the  Medical  Sciences 

"  The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are  : 
First,  its  handiness ;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color,  and  the 
diagnostic  points  which  they  bring  out." 

Mracek  and  Bangs* 
Syphilis  and  Venereal 

Atlas    and    Epitome   of    Syphilis    and    the    Venereal    Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
L.  Bolton  Bangs,  M.  D.,  late  Prof,  of  Genito-Urinaiy  Surgery,  Univer- 
sity and  Bellevue  Hospital  Medical  College,  New  York.  With  71 
colored  plates  and  122  pages  of  text.  Cloth,  ^3.50  net.  In  Saunders' 
Hand-Atlas  Series. 

CONTAINING   71   COLORED   PLATES 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  whom  the 
original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty  anything 
of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Germany,  but 
throughout  the   literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of  "  The  American  Text-Book  of  Obstetrics." 
"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and  graphic 
character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and  the  Venereal  Diseases.'     I  know  of 
nothing  in  this  country  that  can  compare  with  it." 


SAUNDERS'    BOOKS    ON 


Grant's 
Face,  Mouth,  and  Jaws 

A  Text=Book  of  the  Surgical  Principles  and  Surgical  Diseases  of 
the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine ;  Professor  of  Oral  Surgery,  Louisville 
College  of  Dentistry,  Louisville.  Octavo  volume  of  231  pages,  with 
68  illustrations.     Cloth,  $2.50  net. 

FOR   DENTAL   STUDENTS 

This  text-book,  designed  for  the  student  of  dentistry,  succinctly  explains  the 
principles  of  dental  surgery  applicable  to  all  operative  procedures,  and  also  dis- 
cusses such  surgical  lesions  as  are  likely  to  require  diagnosis  and  perhaps  treat- 
ment by  the  dentist.  The  arrangement  and  subject-matter  cover  the  needs  of  the 
dental  student  without  encumbering  him  vi^ith  any  details  foreign  to  the  course  of 
instruction  usually  followed  in  dental  colleges  at  the  present  time. 

Annals  of  Surgery 

"  The  book  is  well  illustrated,  the  text  is  clear,  and  on  the  whole  it  serves  well  for  the  pur- 
pose for  which  it  is  intended." 

Grtinwald  and  Newcomb*s 
Mouth,  Pharynx,  and  Nose 

Atlas  and  Epitome  of  Diseases  of  the  Mouth,  Pharynx,  and 
Nose.  Wy  Dr.  L.  Grunwald,  of  Munich.  From  the  Second  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  James  E. 
Newcomb,  M.  D.,  Instructor  in  Laryngology,  Cornell  University  Medical 
School.  With  102  illustrations  on  42  colored  lithographic  plates,  41 
text-cuts,  and  219  pages  of  text.  Cloth,  ^3.00  net.  In  Saunders' 
Hand- Atlas  Series. 

INCLUDING  ANATOMY  AND  PHYSIOLOGY 

In  designing  this  atlas  the  needs  of  both  student  and  practitioner  were  kept 
constantly  in  mind,  and  as  far  as  possible  typical  cases  of  the  various  diseases 
were  selected.  The  illustrations  are  described  in  the  text  in  exactly  the  same  way 
as  a  practised  examiner  would  demonstrate  the  objective  findings  to  his  class. 
The  illustrations  themselves  are  numerous  and  exceedingly  well  executed.  The 
editor  has  incorporated  his  own  valuable  experience,  and  has  also  included  exten- 
sive notes  on  the  use  of  the  active  principle  of  the  suprarenal  bodies. 

American  Medicine 

"  Its  conciseness  without  sacrifice  of  clearness  and  thoroughness,  as  well  as  the  excellence 
of  text  and  illustrations,  are  commendable." 


EYE,   EAR,   NOSE,   AND    THROAT. 


Jackson  on  the  Eye 


A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the  Eye. 

By  Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye  in  the  Philadelphia  Polyclinic.  i2mo  volume  of  535  pages, 
with  178  beautiful  illustrations,  mostly  from  drawings  by  the  author. 
Cloth,  ^2.50  net. 

In  this  book  more  attention  is  given  to  the  conditions  that  must  be  met  and 
dealt  with  early  in  ophthalmic  practice  than  to  the  rarer  diseases  and  more  difficult 
operations  that  may  come  later.  It  is  designed  to  furnish  efficient  aid  in  the  actual 
work  of  dealing  with  disease,  and  therefore  gives  the  place  of  first  importance  to 
the  conditions  present  in  actual  clinical  work.  A  special  chapter  is  devoted  to  the 
relations  of  ocular  symptoms  and  lesions  to  general  diseases. 

The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence 
of  the  author's  comprehensive  grasp  of  the  subject.  Tlie  term  '  multum  in  parvo  '  is  an  appro- 
priate one  to  apply  to  this  work.  It  will  prove  of  value  to  all  who  are  interested  in  this  branch 
of  medicine." 

Friedrich  am)  Curtis* 
Nose,  Larynx,  and  Ear 


Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in 
General  Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by 
H.  HoLBROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose 
and  Throat  Hospital.     Octavo  volume  of  350  pages.      Cloth,  ^2.50  net. 

INCLUDING  THEIR  SIGNIFICANCE   IN  GENERAL  MEDICINE 

In  this  work  the  author's  ol^ject  has  been  to  point  out  the  interdependence 
between  disease  of  the  entire  organism  and  diseases  of  the  nose,  pharynx,  laryn.x, 
and  ear,  and  to  incorporate  the  new  discoveries  of  these  specialties  into  the  scheme 
of  general  medicine.  The  author  has  endeavored  to  bring  to  the  attention  of  the 
general  practitioner  special  symptoms  and  methods  of  the  greatest  importance  to 
him. 

Boston  Medical  and  Surgical  Journal 

"  This  task  he  has  performed  admirably,  and  has  given  both  to  the  general  practitioner  and 
to  the  specialist  a  book  for  collateral  reference  which  is  modern,  clear,  and  complete," 


14  SAUNDERS'    BOOKS   ON 

0£(den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J,  Bergen  Ogden,  M.  D.,  Late  Instructor  in  Chemistry, 
Harvard  University  Medical  School ;  Formerly  Assistant  in  Clinical 
Pathology,  Boston  City  Hospital.  Octavo,  418  pages,  54  illustrations, 
and  a  number  of  colored  plates.      Cloth,  ^3.00  net. 

SECOND   REVISED    EDITION— JUST   ISSUED 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Important  changes  have  been  made  in  connection  with  the  determination  of  Urea, 
Uric  Acid,  and  Total  Nitrogen  ;  and  the  subjects  of  Cryoscopy  and  Beta-Oxybutyric 
Acid  have  been  given  a  place.  Special  attention  has  been  paid  to  diagnosis  by 
the  character  of  the  urine,  the  diagnosis  of  diseases  of  the  kidneys  and  urinary 
passages  ;  an  enumeration  of  the  prominent  clinical  symptoms  of  each  disease  ; 
and  the  peculiarities  of  the  urine  in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Vecki*s  Sexual  Impotence 


The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vecki,  M.  D.  From  the  Second  Revised  and  Enlarged  German 
Edition.      i2mo  volume  of  329  pages.     Cloth,  ;^2.oo  net. 

THIRD   EDITION,  REVISED   AND   ENLARGED 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  its  pre-eminent  importance  deserves,  and  this  volume  will 
come  to  many  as  a  revelation  of  the  possibilities  of  therapeutics  in  this  important 
field.  The  reading  part  of  the  English-speaking  medical  profession  has  passed 
judgment  on  this  monograph.  The  whole  subject  of  sexual  impotence  and  its 
treatment  is  discussed  by  the  author  in  an  exhaustive  and  thoroughly  scientific 
manner.  In  this  edition  the  book  has  been  thoroughly  revised,  and  new  matter 
has  been  added,  especially  to  the  portion  dealing  with  treatment. 

Johns  Hopkins  Hospital  Bulletin 

"  A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The  treatmenH: 
of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and  judicious." 


CHEMISTRY,  SKIN,  AND   VENEREAL   DISEASES.  15 

American  Pocket  Dictionary  °      just'iss"ued^'^"^ 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A. 
Newman  Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania.  Containing  the  pronunciation 
and  definition  of  the  principal  words  used  in  medicine  and  kindred 
sciences.  Flexible  leather,  with  gold  edges,  ;^i.oo  net ;  with  thumb 
index,  $1.2^  net. 
James  W.  Holland,  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 
Philadelphia, 

"  1  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  I 
can  recommend  it  to  our  students  without  reserve." 

Stelwagon*s  Essentials  of  Skin  Fifth  Revised  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
WAGON,  M.  D.,  Ph.D.,  Clinical  Professor  of  Dermatology  in  Jeffer- 
son Medical  College  and  Women's  Medical  College,  Philadelphia. 
Post-octavo  of  276  pages,  with  72  text-illustrations  and  8  plates. 
Cloth,  ^i.oo  net.     In  Saunders'  Question-Compend  Scries. 

The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been  noted." 

Wolffs  Medical  Chemistry  ^'"^HftZ^.T'^ 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  Smith  Ely  Jelliffe,  M.  D.,  Ph.D., 
Professor  of  Pharmacognosy,  College  of  Pharmacy  of  the  City  of 
New  York.  Post-octavo  of  222  pages.  Cloth,  ^i.oo  net.  In 
Saunders'  Question-  Coinpend  Series. 
New  York  Medical  Journal 

"  The  author's  careful  and  well-studied  selection  of  the  necessary  requirements  of  the 
student  has  enabled  him  to  furnish  a  valuable  aid  to  the  student." 

Martin's  Minor  Surgery,  Bandaging,  and  the  Venereal 

Diseases  second  Edition.  Revised 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clin- 
ical Surgery,  University  of  Pennsylvania,  etc.  Post-octavo,  166 
pages,  with  78  illustrations.  Cloth,  $1.00  net.  In  Saunders' 
Question-  Conipend  Series. 
The  Medical  News 

"  The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed  before  the  pro- 
fession." 

Jelliffe  and  Jackson's  Chemistry 

A  Text-Book  of  Chemistry.  B\'  Smith  Ely  Jelliffe,  M.  D., 
Ph.D.,  Professor  of  Pharmacognosy.  College  of  Pharmacy  of  the 
City  of  New  York;  and  Holmes  C.  Jackson,  M.  D.,  Assistant  in 
Chemistry,  University  and  Bellevue  Hospital  Medical  College, 
N.  Y.     Octavo,  550  pages,  illustrated.     In  Preparation. 


i6  URINE,  EYE,  EAR,  NOSE,  AND    THROAT. 

Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M.  D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New- 
York.    1 2mo  volume  of  204  pages,  fully  illustrated.  Cloth,  ^1.25  net. 

British  Medical  Journal 

"  The  methods  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book   some   extensive   tables   drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  PolycHnic.  Post-octavo  of  261  pages,  82  illus- 
trations.   Cloth,  ^i.oo  net.     In  Saunders  Question- Compend  Series. 

Johns  Hopkins  Hospital  Bulletin 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason*s  Nose  and  Throat  Third  Edition.  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  1 12 
illustrations.     Cloth,  ^i.oo  net.      /;/  Saunders'  Question  Compends, 

The  Lancet,  London 

"  The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of  the  Ear  Third  Edition.  Revised 

Essentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.     Post-octavo   volume  of  214  pages,  with   114  illustra- 
tions.    Cloth,  ^ I. GO  net.     In  Saunders'  Question-Compend  Series. 
Bristol  Medico-Chirurgical  Journal 

"We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  information." 

Wolffs  Essentials  of  the  Urine 

Essentials  of  Examination  of  Urine,  Chemical  and  Micro- 
scopic, FOR  Clinical  Purposes.  By  Lawrence  Wolff,  M.  D., 
Late  Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Phila- 
delphia. Post-octavo,  66  pages,  illustrated.  Cloth,  75  cents  net. 
In  Saunders'  Question  Compends. 

Brockway's  Medical  Physics  second  Edition.  Revised 

Essentials  of  Medical  Physics.  By  Fred.  J.  Brockway, 
M.  D.,  Late  Assistant  Demonstrator  of  Anatomy,  College  of  Physi- 
cians and  Surgeons,  New  York.  Post-octavo,  330  pages  ;  155  fine 
illustrations.     Cloth,  ^i.oo  net.     In  Saunders  Question  Compends. 

Medical   Record,  New  York 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously 
illusfrated." 


RD523 


G76 


